Cognitive load with the EHR and burnout:

why aren’t we measuring this more?

Dr. Elizabeth Harry, image from twitter

https://www.sciencedirect.com/science/article/abs/pii/S1553725020302464

Thank goodness for smart colleagues. Dr. Elizabeth Harry is first author on an important work that ties physician/provider task load to burnout. See link above. 

Using the NASA task load index, and the Maslach burnout inventory, she was able to demonstrate a substantial correlation with an increased task load (mental, physical, and temporal demands, and perception of effort) and burnout.

Far from pointing the finger at EHR’s alone, task load generalizes across many industries, with electronic tools such as the EHR being a major negative or positive influence.

I can see a fruitful future line of investigation and collaboration with this measurement tool.

CMIO’s take? How are YOU measuring and tackling provider burnout?

My Failure Resumé (a talk)

What lessons can we learn from CT Lin’s failures?

Thanks to the Colorado Chapter of HIMSS (Health Information Management Systems Society) and to Bonnie Roberts and Rich Morris for co-hosting my presentation.

Based on my recent Failure Resumé 1 pager. Here are some personal stories, life lessons, and 3 exercises to help you build a failure-tolerant future.

With, of course, a bonus ukulele song at the end.

CMIO’s take: Have you written a failure resumé? Are you building a failure tolerant future? Let me know in the comments.

The Eppendorf, CRISPR, Covid, and my medicine origin story

This post is THREE THINGS. A personal origin story, a (brief) book review, and a connection to recent stories on Pfizer and Moderna Covid vaccines. And, when we’re done, it might even tie together!

Image above: Dr. NoFronta Lobe, Mad Scientist. No this is not me in the research lab; this is me, a kindergarten parent at Halloween

My Origin Story (I was a budding molecular biologist in 1985)

I was alone in the brightly-lit sterile-white research lab; having spent 20 hours on a long, multi-day experiment. It was nearly midnight on Saturday in 1985. I was a college junior majoring in molecular biology, with aspirations of a scientific research career. I was studying P4 bacteriophage, a virus that attacks E coli bacteria.

The work sequence, I could now perform by heart: inoculate, incubate, centrifuge, enzyme reaction, pipette (fancy eyedropper tool) into an Eppendorf tube (a tiny plastic tapered tube. From a Q-tip-loaded with a single bacterial colony, I had carefully grown a quart of bacterial culture, then sequentially purified my sample down to 20 drops of a pearlescent white DNA solution.

So: 20 hours for 20 precious drops. 

Eppendorf tube, Fisher Scientific

Exhausted and looking forward to heading home, I was on my last steps before overnight refrigeration, so as I held the open Eppendorf in my left hand and my pipette in the right, I randomly thought: “What time is it? Am I going to miss the last Orange Line train going home?”

So, I moved to look at my watch…

And since my watch is on my left wrist, the Eppendorf tube in my left hand did a 180…

And I watched as all the liquid ran out … and onto the floor. 

I looked at the upside down Eppendorf, and then down at the floor and the drops of liquid there, uncomprehending. 

*How… what… nnnnnNNNNNOOOOOOOOOOO!!!*

My late-night-fogged brain finally registered SHOCK, DENIAL, ANGER, BARGAINING. The lab was deserted, I deemed it safe to express myself:

“F$*&@! S!#%! D&$%!” I said, eloquently.

Desperate, I dropped down and started using the pipette to suck up DIRTY droplets of DNA extract from the floor and replace it into the Eppendorf. After a few minutes I had about 1/3 of the liquid, now brown-tinged, back in the tube. Resigned, I put the tube in the fridge. 

NO time to fret, no time to start over. Nothing else to do. I got on my jacket and faced the Boston winter, and jogged for the Orange Line stop. 

Once on board that last train, I started to sob. There was no way that soiled sample would be any good. This COMPLETELY SUCKED. 

And, I realized, I really did not want to be here. I realized: I could do the scientific work, but, unlike some colleagues who revelled in long hours in pursuit of new knowledge, I was despondent, not very good at this, and missed being around people. 

That was the night I decided that bench research was not for me. I had thought my calling was in pure science, but this DNA catastrophe taught me where I didn’t want to be. I needed Humanism AND Science. So, medical school it was. I’ve never looked back. 

Molecular Biology after 1985 (CRISPR!)

Thirty-five years later after my profanity-laced change of career, Walter Isaacson chronicles the recent successes of genetic research, including the discovery of CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) and CAS9 (CRISPR ASsociated protein #9).

Book review rating? 5/5 stars.

In a nutshell: Jennifer Doudna and Emmanuelle Charpentier, and many others raced to understand these strange “repeating sequences” in DNA and mRNA, realizing that they were bacterial defenses against “phage” viruses.

In this work, they discovered that CRISPR-Cas9, an mRNA plus protein complex could identify attacking virus mRNA and SLICE IT UP, deactivating it. They realized that this ancient protein complex could be taught to identify ANY RNA or DNA. Gene editing, invented by bacteria as a survival mechanism a millenia ago, co-opted by humans. Precise genetic scissors.

I enjoy Isaacson’s writing style. Not only does he clearly explain the adrenaline rush of scientific discovery (and the delicate dance between scientific sharing versus the race against other labs to publish and claim credit), but also the technical details of how CRISPR works.

Isaacson writes about Doudna and the response to Covid-19. What is even more astonishing about Dr. Doudna, the bench researcher and lab leader at Berkeley, is that she had the socio-political skills to bring together 40 leading geneticists across the Bay Area to successfully set up a brain trust to develop Covid-19 testing and vaccine development. This team lays much of the groundwork of the accomplishments of this past year.

Drs. Doudna and Charpentier were, deservedly, awarded the 2020 Nobel Prize in Biology “for the development of a method for genome editing.”

A personal note: my brief journey in molecular biology never quite crosses Dr. Doudna’s path, but I recognize the genetic tools mentioned, and studied the work of the luminaries in the field. I feel like a distant cousin to these scientists.

Highly recommended read, to understand the genetic foundation of our modern age.

Molecular Biology: the Covid fight

Here are 2 stories about Covid Vaccines, from the New York Times and WIRED.com, fascinating glimpses into the genomic-industrial complex. As of May 14th 2021, 36% of US adults are vaccinated against Covid-19. It is highly likely that these speedier and more effective mRNA-based detection tests and vaccines will forever be part of our lives. This could shorten development and improve accuracy of future vaccines.

WIRED.com story on Moderna’s Covid Vaccine trials

https://www.wired.com/story/moderna-covid-19-vaccine-trials/

CMIO’s take? Our modern world is built from advances in scientific method, computing and now genome editing. Despite my early failure in the lab, I feel fortunate, in the field of medical informatics, to be close to all 3.

INFORMATICS: Put the road signs on the road, not in the garage

Why make folks go to training or read a tip sheet if you could guide them just-in-time as they do their work?

Here’s a lovely example of our Physician Informatics Group (Large PIG) evolving as we improve the “intelligence” that our Electronic Health Record (EHR) supplies to our hardworking providers (physicians and advanced practice providers).

In the past

clinicians might have pulled up an app on their smartphone dedicated to the ASCVD: atherosclerotic cardiovascular disease RISK CALCULATOR, punch in some numbers and get a result to type back into the EHR.

Later on, some well known national websites would do the calculation for you. Still requires finding the website and typing in numbers.

Even later, we would put hyperlinks within the EHR to link you automatically, but the typing was still required to get an answer.

NOW

we have built a smartphrase (while using the EHR, in any text field, type “.ASCVDRISK”, hit the RETURN key, and Voila, the answer above:

Risk calculated based on what the EHR knows about your patient: age, sex, diabetes, smoking, blood pressure, cholesterol. AND THE ANSWER: 9.1%. FURTHERMORE, disappearing help text guides you to use this information appropriately, and only saves the relevant info to keep in your progress note.

My colleague’s wonderful metaphor for Clinical Decision Support like this?

Put the road signs on the road, not in the garage.

It is already hard enough to use an EHR with patients. Don’t make me go looking for that training document from weeks or months ago, don’t make me think. Make it easy to do the right thing. It is a small celebration every time we can do this right.

CMIO’s take? Thanks to Rich Altman MD for a beautiful new tool in our system. What road signs can YOU take out of the garage and put on the road?

Info Blocking Rule is coming 4/5/2021. Here is some last-minute help for health systems

Break down those barriers!

Well, it is finally here.

The 21st Century Cures Act has an Information Blocking Rule that goes into effect as of April 5, 2021. It was originally supposed to launch in November of 2020, but the federal government told us “JUST KIDDING” 3 days before and delayed until 4/5.

Because we laid all the groundwork and also felt it to be the RIGHT THING FOR PATIENTS, we went ahead and launched our changes in November, and SURPRISE: I still have a job, wasn’t fired. Thanks to our MMOLC sharing community.

A brief reminder

The rule stipulates that patients should be able to receive a copy of

  • Test Results (laboratory, pathology, radiology) and
  • Their Provider’s (physicians and advanced practice providers) Progress Notes

upon request. The interpretation was that if a patient had a Patient Portal account in the EHR (electronic health record) of the clinic or health system, this meant immediate release of this information. This is a major change for many health systems who had not yet adopted Open Notes (release of progress notes) or delayed the release of test results by several days.

Since our adoption of Immediate Release

of Progress Notes and Test Results since November of 2020, I have had exactly 2 complaints reach my desk, both from oncologists representing unhappy patients who read their CT imaging study on Friday evening and had difficulty reaching their doc until Monday. This is in the setting of about 1 million clinic visits, 800,000 radiology studies, 30,000 hospital stays, millions of lab and pathology results in these last 4 months.

So, not perfect, but not nearly the “sky is falling” result, as anticipated by many colleagues.

In case you’re still working through this, here are some documents (some updated) that we used. Some are actually named Information SHARING instead of BLOCKING, just a more hopeful attitude. I hope these might help you. Images here, links to full PDFs further down.

Even better, our colleagues at OpenNotes.org are doing some terrific office hours with experts online where you can hear the real-life experience of leaders ALREADY doing this work in various fields, successfully.

CMIO’s take? Are you ready? Do you have documents YOU can share? Lets do this!

COVID Vaccines at Colorado’s Epicenter from March 2020: JBS Greeley Beef meat packing plant.

Changing minds with Stories, not Data.

NEWS ARTICLE: https://www.greeleytribune.com/2021/03/05/jbs-workers-having-seen-the-largest-outbreaks-in-weld-county-receive-first-doses-of-covid-19-vaccine/

This was a remarkable event, and I’m glad I was there to see it.

For those who may not know or remember; Greeley’s JBS meatpacking plant was the center of Colorado’s first major outbreak of COVID illness, resulting in numerous deaths and hundreds of workers getting sick and hospitalized. Meatpacking requires close quarters, and one infection spread rapidly to many.

I watched on the news with horror as the disease spread, and Greeley, a small town in rural Colorado became national news. Greeley also led the state in COVID illness early in the pandemic.

Public Health Effort

The great news NOW, is that Colorado’s Public Health coordinated a multi-health-system effort to vaccinate the nearly 5000 employees there. When I heard of the opportunity, I dropped everything and headed up there last Friday to be part of the effort.

It would seem an insurmountable task: How do you coordinate nearly 100 volunteers who don’t know each other, in a noisy, unfamiliar plant? How do you incent workers who may have questions about the vaccine, to come discuss and be vaccinated? Will you have enough translators (at least 8 languages are spoken by employees)?

7 health systems coordinated

Soon, however, we got organized into 14 tables of 3 vaccinators, taught how to load vaccine syringes from defrosting Pfizer -70 degree vials, supplies distributed, and employees started rolling in, paper consents in hand.

Doctors, nurses, medical assistants, technicians, healthcare workers speak the same language. Despite the cold hallway, we buckled down and got to work.
Dr. Hoffenberg instructing each table on standard vaccine process.
Patients arriving by the hundreds

2500+ vaccinated

We vaccinated over 2500 employees on Friday, a great day and smooth operation. See above for the write-up by the Greeley Tribune, among many news organizations on site.

The “Education Room”: Stories NOT Data

Here is where it gets interesting. I found out that I was assigned to the “Education Room” upstairs. Management at JBS was serious about maximizing employee engagement with this big push for vaccination.

  • The plant was closed for 2 days.
  • All workers would be paid for 4 hours of shift work JUST TO SHOW UP.
  • All workers who got vaccinated would receive an additional $100.
  • All workers who declined vaccine could sign a paper … AFTER they went to the EDUCATION ROOM where Dr. Lin and other physicians and nurses were waiting
Image blurred intentionally

Hmm. I thought I had signed up to vaccinate today …

When I heard this, my life flashed before my eyes. Not really, but I had a rapid sequence of thoughts:

  • I hoped they had enough translators (turns out, yes: Somali, Spanish, Amharic/Ethiopian, many more)
  • I hoped I had heard most of the rumors and misinformation about the vaccine before and be ready to respond
  • I hoped that I could avoid STATISTICS and DATA, since most vaccine-decliners have (mostly misinformed) STORIES. Data never beat a compelling Story. Only Stories have a chance to fight Stories in the battle for feelings and changing minds.
  • I thought back to a book I read recently, The Righteous Mind, about values, moral thinking, and how those with liberal values, and those with conservative values see morality with very different lenses. Would I be able to speak a common language to connect with those who saw the world differently?

Reasons why NOT?!?

Yes, it turns out, we only had about 100 people come through for the 6 hours I spend there. Of the 100 we spoke with, I heard a dramatic range of reasons why people were declining the vaccine:

  • “Well, it’s not a real disease anyway.”
  • “I heard the vaccine kills people.”
  • “The vaccine is only 95% effective. So what is the point? Like, it doesn’t even work.”
  • “I heard it is made from dead babies.”
  • “Only old people have a problem with COVID.”
  • “I am healthy. I don’t live with old people. I don’t need it.”
  • “My roommates will make fun of me. We are not getting it.”
  • “My parents told me not to get it.”
  • “Why are WE the guinea pigs, before everyone else?”
  • “I’m going to wait and see.”
  • “I’m pregnant. I heard it is dangerous for my baby.”
  • “I already had COVID. So, I’m immune.”
  • “I never get ANY shots, flu, nothing. I don’t need it.” (and more)

This was a daunting task. However, we had a room full of translators for all languages, 3 tables set up with information sheets and 3 cultural ambassadors to explain the importance of the vaccine and WHY JBS managers and leaders thought this was important, and even Union Leaders who would show videos of themselves getting the shot themselves (thank you JBS; very organized!). THEN, if the participant was adamant about their decision, fine, go sign the paper and get paid.

Less Helpful Conversations?

IF they had a question, one of us would get called over, and we could chat. I heard a few discussions in the room. Some less effective approaches:

Employee: “I don’t want the shot. I already got COVID. I’m immune.”
JBS Supervisor: “I haven’t got COVID. I’m not immune. You don’t care about me?”
Employee: “Nah man, stop talking. Where do I sign the paper.”
(Confrontational)

Employee: “I don’t want the shot. I’m healthy.”
Medical advisor: “You know, the shot is 95% effective. Even though it doesn’t protect everybody, the data shows that almost everyone gets immunity. Even if you DO get the infection, it is likely milder and you won’t have symptoms.”
(Data-heavy, confusing, and not addressing the issue)

Employee: “It is not a real disease.”
Medical advisor: “Yes it is. People die all the time. Here are 5 reasons the shot is safe and the evidence that it works…”
(Not enough reflective listening, eliciting thoughts, trying to find common ground, and too much talking)

Whew. I could see myself falling into each one of these traps. I set myself a goal to find STORIES to match and counter their STORIES and to suppress temptation to exhibit my command of the DATA (sooo hard).

Better Conversations?

Here are some of the better ones we came up with. Importantly, ALWAYS begin with “What questions do you have?” and “Tell me more about what you understand.” and “Anything else?” and “I like that you are trying to get good information before making a decision. This can be very confusing and scary. I would like to help.”

Employee: “I’m pregnant. I’m afraid for my baby.”
Me: “Yes, there is less information from the vaccine tests about pregnant women. HOWEVER, MOST of the women doctors and nurses at University Hospital who are pregnant have gotten the shot. And we are confident it is safe for the mom and baby.” (result: agreed to shot)

Employee: “I heard the shot makes you sick.”
Me: “Well, most people do not get sick. If they do, some get a sore arm, or a headache or fever, like getting the flu. Tylenol helps. For me, I had a fever for about 3 hours overnight.” (result: agreed to consider it later)

Employee: “Why are we the guinea pigs and getting it early?”
Medical advisor: “Actually, the doctors and nurses were the guinea pigs; they got the shot back in December and January. We are all healthy and staying safe, with no major side effects. We want YOU to be protected too.”

Employee: “I just don’t want to do it.” (unable to state a clearer reason)
Me: “I hope you see all the doctors and nurses in this room. We are all volunteers, took a day off to come here, because we WORRY about you and your community. You are Essential workers. Last year, many of your co-workers got sick and died, and we did not protect you. We don’t want this to happen again.” (result: thanked us for volunteering, and promised to consider vaccination)

Motivational Interviewing?

Of 100 people, about 20 agreed to the shot during our session, about a 20% conversion rate. Is this normal? I have no idea. One of my colleagues noted:

“Compared to vaccinating, this is soul-crushing. To do your best explaining why a crucial vaccine would save lives IN THIS PLANT, and not to connect. So hard.”

Nurse Practitioner in the Education Room at JBS

At the same time, we all agreed that many of the decliners also said they would think about it some more, and would consider getting it later. In motivational interviewing lingo, perhaps they were moving from “pre-contemplative” to “contemplative.” Even a mild attitude shift like that, is a win.

Some of the more effective strategies:

  • Listening more than talking
  • Finding common values: “The Broncos!” or “Protecting elderly parents”
  • Telling a personal story of COVID or getting vaccinated and how it felt
  • Talking about “looking out for each other” “protecting our community” “making Colorado safe” “keeping Covid out of your family”
  • Using metaphors: “Which vaccine? Its like, Dodge, Ford, Chevy. Just get in the car. We will all get there.”

Dr. Steve Hoffenberg, Emergency Medicine Physician, coordinated the vaccine efforts at JBS. Thank you, Steve.

FINALLY: Will you look over this document with me? I wrote a ONE PAGE summary of what I thought were the BEST STORIES to fight misinformation about COVID Vaccine. What do you think?

Download the document here: https://www.dropbox.com/s/k94xra38b4tmmst/2021-0309%20Why%20Should%20I%20Get%20the%20COVID%20Vaccine%20CTL.pdf?dl=0

CMIO’s take? Wow, there is a lot more to vaccine work than “give shot, call next patient.” Coordinating a public health effort: massive. Focusing on high risk populations: important. Listening, connecting and changing minds: some of the hardest work of all. In the coming months, THIS will be the conversation.

SNAFU tent: Optimizing a Covid-19 Mass Vaccine effort at Many Levels

Dancin’ away troubles at UCHealth’s SNAFU tent for Covid Mass Vaccination

Optimizing the Mass Vaccine Event

This will be a fun exploration from a CMIO’s perspective. Let’s think about individuals and work our way up to national optimization, from a personal perspective. And, don’t miss the SNAFU Tent Vaccine Dance at the end…

Seven Levels of thinking

  • Level 1: Make myself efficient
  • Level 2: Make my pit-crew efficient
  • Level 3: Make all pit-crews efficient
  • Level 4: Make the entire Mass Vaccine efficient
  • Level 5: Optimize Mass Vaccine for volume or cost
  • Level 6: Optimize Health System Vaccination plan
  • Level 7: Optimize National Vaccination

1. Make myself efficient

Readers may remember recent writeups where I incrementally overcome my lack of skill as a physician at vaccinating. I’m a quick study, and when great nurses and medical assistants are around to teach, I got better quickly. See above, with the pre-peeled bandaid/ vaccine/ alcohol swab grip, and second hand to manage the smartphone electronic documentation. I’m MOB-ILE.

Here’s the set up: have an assistant play “keep ahead” by peeling bandaids. The hardest part of the job is peeling bandaids with gloves on.

The next hard part is that vinyl gloves stiffen in cold weather. So, use the sani-wipe jug to elevate your glove box closer to the propane heater. Smart! Actually even that wasn’t really warm enough, so I took to doing this:

I call this “praying to the propane gods.” Or, holding the gloves up for 5 seconds of warmth: makes a huge difference in the ease of putting them on (150 times that day).

Handwarmers: Even better idea

Of course, Bernice comes to me near the end of the day and tells me “Dr. Lin, put 2 handwarmers in your coat pockets and put your next pair of gloves in them, so you always have warm gloves to swap.

“D’oh!” as Homer Simpson would say. Why didn’t I think of that?! Thanks, Bernice.

Colorado Rockies’ Dinger drops by

2: Make my pit-crew efficient

This section is actually mis-labelled. My pit crew made ME efficient. Unlike previous days, where I built up such an efficient process that I was able to stay ahead of my pit-crew colleagues in our 4-car pit-stop, today I was teamed up with 3 outstanding medical assistants from Lowry Internal Medicine, my own UCHealth clinic in Denver: Marina, Yanira and Bernice. The tables were turned: now, every time I looked up from my completed vaccination, the other cars in my pit had already gone! Too fast, gals! You’re too fast for me. 😦

Team Lowry, with my BFF’s.

View of the Mega tent with 4 of the 8 rows, and the pharmacy (vaccine reconstitution tent to the right). The other 4 rows are out of sight to the right of the pharmacy tent. We can vaccinate 32 cars in 8 rows at a time this way. Furthermore, we would huddle and learn from each other “How are you going so fast? What is your set up? How do you ask the screening questions? Where do you put the sharps container?” etc. Thank you, smart colleagues, for teaching me.

3: Make all pit-crews efficient

To further smooth the process, given what we had learned on previous weeks, we posted 4 SNAFU tents after the Mega-tent that we would refer to for any slow-downs or technical concerns. For example, one car pulled up with 3 people to be vaccinated. I would perform one vaccination, and since my row was ready to roll by then, I would place a red card on the windshield, indicating SNAFU and the flaggers would direct the car to receive the remaining 2 shots about 100 yards away. This simple workflow adjustment (4 SNAFU tents for all 8 pit-crews) kept ALL 8 lines moving. This was a difference (for me) between vaccinating 124 people one day and 158 the next. Super smooth.

Another example: a patient drove up and their Electronic Record account showed “second vaccine already administered.” I couldn’t solve it with my smartphone Rover app, so I referred him to the SNAFU tent.

After some investigation, we found out later that day, it turns out that another organization in town had incorrectly registered that patient (a common first and last name and somehow erroneously documented date of birth) so that the mistaken vaccine APPEARED in OUR system on this patient (our separate Epic EHR’s share vaccine records now) that he had already had his second shot (incorrectly). We presume this was because some institutions are still using a paper-vaccination process with “document later” staff (as we did last month, in favor of speedy vaccinations). This re-introduces errors that the EHR was supposed to eliminate (bad handwriting and transcription errors). Hmm.

We are glad we are now using the Rover smartphone app. We’ve tinkered with it so that it is now possible to be as fast with Rover as with paper (AND eliminating the transcription step). 50 seconds with paper, and 50 seconds with Rover. Ha!

4: Make the entire Mass Vaccine efficient

We had lots of competing concerns to keep in mind, when thinking about the entire effort. Police were concerned about backing up waiting cars into nearby streets. (whew, we avoided this). How many total staff were needed to register patients? (too many in version 1) How many tents to rent for these events? (originally 1 mega and 18 cabana-style tents, now 1 mega and 2 cabanas) How would we deal with inclement weather? (snow, rain, black ice, wind: the mega-tent is superior to cabanas for keeping staff out of the weather and minimizing wifi and cell-booster mesh network issues; FYI, my new 5G iPhone 12 pro max was awesome in our pilot testing for speedy smartphone documentation)

Our diligent road crew out there dodging and managing tent-avalanches.

We have been pleased to constantly drive down out patient-throughput times, down to 22 minutes (including the 15 minute observation period)! And this past week on Sunday, we drove our total time down to 16 minutes in some cases: 1.5 minutes for registration, vaccination, a couple minute driving time, and then a 10-minute observation period. Wow. We believe we are the fastest Mass Vaccine service in the country at this rate. Even better, we are making observation OPTIONAL going forward, because of our non-existent severe reaction rate.

We believe we can expand beyond 10,000 per weekend, and believe we can do 20,000 or possibly 26,000 per weekend, if the State has vaccine supply and would like us to.

5: Optimize Mass Vaccine for volume or cost

So, what is the goal of a Mass Vaccine event? Publicity for vaccination? Sure, we had news helicopters circling, lots of press, lots of people commenting on how easy it was, and how much they’re looking forward to hugging grandkids.

We can optimize for convenience for frail elderly. Sure, stay in your car from home, back to home, no walking. Can we help people avoid healthcare settings? Sure.

We can optimize for speed: in which case, bring more vaccinators, and rent a second mega-tent. There is room in this massive parking lot for more staff, we can create more lanes and instead of 32 at a time, we could do 48 cars or more. 20,000 per weekend is entirely conceivable, if vaccine supply were up to it (not yet).

Or, we can optimize for lower cost. With our original full teams in the early weeks, we overstaffed and calculated a per-vaccine operating cost in the mid $20’s. Of course, the vaccine itself, is free to us and patients, paid for by the feds. But, tents, staff, project managers, coordinators with police, state, county and city government, vaccinators, training team, pharmacy team, coolers and vaccine supply chain management, traffic tents, snow removal, medical observation team, volunteer-coordinating managers, paramedics, command center coordinators, walkie-talkies, workstations on wheels, smartphone devices, wifi repeaters, cellular repeaters, scheduling of appointments, design of vaccine clinics… pretty soon it is a big operation. After a couple days, and constant re-design, we were able to trim operations down into the $17 range.

6: Optimize Health System Vaccination plan

First Covid Mass Vaccine design, last month, at Coors Field, Denver

Vaccinating patients on-site at University of Colorado Hospital, Bruce Schroeffel Auditorium

Outdoor vaccine guy vs Indoor vaccine guy

AND THEN. We compare our Mass Vaccine efforts to our ongoing (but less splashy) vaccine clinics in 10 facilities across UCHealth, spread across the entire state of Colorado, at even lower per-vaccine cost, with the capability of 5,000 to 10,000 per day. We are hiring permanent staff to run these vaccine clinics and stop borrowing from clinical teams across our system, as we think we will be doing this for quite some time.

Volunteers?

It is gratifying that we have lots of folks (many retired) willing to volunteer their time. The challenge with accepting this help is: it can be more expensive to run a scheduling calendar and training for hundreds (?thousands) of part-time (or one-time) volunteers than it is to have a reliable, skilled steady crew to take care of business. For the rare volunteer who COULD come regularly (for 8 or 10 hour shifts!) (for months!), that would be a blessing. And, as this vaccine saga goes on, we may indeed need more help.

Pop-up Outreach Clinics for the medically Under-served

Another effort I’m grateful for, are our Pop-Up vaccine clinics. We are taking our show on the road to multiple community centers and churches in medically under-served neighborhoods, where leaders are helping us schedule thousands of vaccination appointments among their neighbors. I’m heading to several in the coming weeks. (stand by for more posts from the front lines!)

UCHealth has given 270,000 vaccines, about 20% of Colorado’s total to date.

Yup, you read that right.

From this graph, you see our green Mass Vaccination events occurring on 2 weekends. Dark blue is University Hospital with over 13,000 vaccines given per week, and our other regions similarly. Light blue is South region, Purple is North region. Red includes our small hospital and outreach clinics at about 10,000 a week. Again, limited by supply.

7: Optimize National Vaccination

A rising tide lifts all boats.

For those interested, UCHealth has published a playbook for other organizations: https://www.uchealth.org/covid-19-mass-vaccination-planning/ with lots more details.

And Finally: a SNAFU Tent Vaccine Dance?

Is this real? Apparently, yes. Dr. Jonathan Pell and our elite crew of SNAFU tent staffers put together a dance invitation for upcoming cars.

I was surprised to find out how many younger colleagues had never heard of the term SNAFU.

The good news? Our process worked so well, the SNAFU team did not have much to do, a few cars here and there during the day. So much time, in fact, that they came up with their own DANCE.

I have no words.

CMIO’s take? How to get better in Seven Different Ways. Let’s go!

Covid Be-Gone. 10,000 Vaccines, One Weekend: UCHealth @ Coors Field.

Billie, Alex, and some crazy doctor, newly recruited Pit Crew. Biggest innovation? Billie’s smiling face on her button! Why haven’t we all done this!?

Our team is at it again!

The Rockies and Coors Field welcomed the UCHealth crew, this time for a 2-day, 10,000 vaccine event Jan 30 and 31. It was a smashing success, and tremendous fun, to boot.

Our fearless leader, Ali Hererra, giving last-minute tips to an eager 630am crew.

The new kid on the block

The new kid on the block: a neck-lanyard, battery-pack augmented iPhone with the EHR mobile app installed for on-the-fly vaccine documentation from QR bar-codes.

Gratitude!

Our vaccine clients show tremendous gratitude; we love the spontaneous cheering and applause that break out at times while the cars are moving through. One even handed us an unexpected gratitude card today!

What’s the count?

Here’s my tally for one day of vaccination: 150 for each day, 300 for the weekend. Unanticipated outcome? Donning and doffing gloves 150 times in quick succession causes some hand irritation and a need for heavy doses of vaseline petroleum jelly at the end of the day.

I proudly showed my clinical informatics colleague my collection of vaccine caps in my pocket (see how clever I was to keep track of my productivity?), and she promptly told me: Well, it is easier just to run a report (Thanks, Kristin). Um-hm. And I call myself a CMIO.

Efficiency tip?

Efficiency tip? Here’s the latest: Non-dominant hand: bandaid on the thumb, half peeled. Vaccine, ready to go. Pre-peeled alcohol swab. Dominant hand: Mobile device on a lanyard or in a coat-pocket, QR code scanner ready, some quick screening questions and screen-taps, vaccine documented in EHR, give vaccine, walk back to tent and re-supply while our student hands out the vaccine card and follow-up instructions. Rock-and-Roll.

First of all, our team CRUSHED the scheduled volume today. At our peak, we vaccinated more than 1000 people per hour, with average throughput times of 22.5 minutes (that’s INCLUDING the 15 minute observation).

To say that another way: we timed cars arriving at Check-in Registration at time ZERO, got screened, registered, consented, and vaccinated in about EIGHT MINUTES. And 15 minutes after that, they were rolling out of the observation area. WAT?!

We had numerous people exclaiming: “This is unreal, how smooth it is.” With masks on, we’re getting good at reading the smiling eyes. Wave after wave of grateful vaccine recipients.

Current Vaccine Tent workflow

The Tent 8 “A-team.” Billie Martinez, medical assistant, Brittney Poggiogalle, PA student, Alexander Jimenez, medical assistant (working hard). Thanks for making us all look good!

Turns out it is easy to “infect” colleagues with the enthusiasm I have for optimizing our workflow, which is now:

  1. Vaccinator sets up the non-dominant hand with vaccine, bandaid and swab (see above)
  2. Patient arrives with QR bar code ready on their phone (from My Health Connection or a printout). No Bar code? No problem, a last name search is only a few seconds more. Beep! 3 screening questions, done!
  3. Vaccinate! (previously described)
  4. Pivot our positions, and our student volunteer steps up and hands the vaccine card with followup instructions to proceed to observation area and to NOT MISS their next appointment (already booked for 3 weeks from now).
  5. DONE! our best cycle time: ABOUT 70 SECONDS INCLUDING DOCUMENTATION.
  6. Perhaps even more exciting, talking to each other about Lean process, discussing throughout the morning, how to stay safer: remember to tell drivers to put it in Park! Remind each other as we walk up and down, to stay out of the driving lane! When standing at your work table, prep your supplies with your body turned facing the line to be aware of your environment. Tell each other if you see something to improve.
  7. All 3 vaccinators have their own neck-lanyard mobile documentation tool, and we can give about a vaccine every 1.5 to 2 minutes including drive-up time, and one student keeps us supplied with peeled bandaids, filled-out vaccine cards, and explains next steps to the drivers, allowing the vaccinators time to re-set for the next care. It is a beautiful dance.

A Lean Lecture?

Talking with a colleague later, I reflected that I got so excited about our efficiency, that I gave a mini-lecture during the morning to our team and student volunteer on Lean process. My colleague then replied: “Oh no, Student! Wrong Tent! Wrong Tent!” implying that no student needs a lecture from an over-enthusiastic CMIO on a weekend. (Thanks for the commentary, Dr. Bajaj).

Our previous worries about backlog of paper charting needing later data entry?Gone!

The cool thing about this setup is: we did not pre-identify which cars had slow-down factors like: more than one scheduled vaccine recipient per car, no bar-code, occasional technical glitch, or lots of clinical questions. Occasionally, if one car took a little longer, the other 2 vaccinators would walk up the line and greet the next car. Once the line opened up, everyone slid forward easily. A handheld mobile and a one-hand vaccine supply made us nimble. None of us was waiting around, unless our line of cars emptied out entirely.

I enjoyed hearing the pharmacists on-site, who were mixing up batches in real-time (the Pfizer: needing to defrost and reconstitute from -70!), on the walkie-talkies discussing which tents needed more vaccine: “We’re almost out again at Tent 8.” “Okay, on the way with another batch of 25.” With our throughput (3 vaccinators, cycle time about 2 minutes simultaneously), that batch would only last us about 18 minutes. Loved every minute of it.

The CMIO in me wanted up-to-the-minute vaccine stats from the other tents. Not that I was feeling competitive. No. Not me.

The Pit Crew

Not being satisfied with even this, mid-morning we were asked to transition to a Pit-Crew method being piloted by our Clinical Informatics nurses. In our standard lanes, cars would pause at one of 6 Registration lines, drive down a lane and then be split into 16 vaccine tents. The Pit Crew were doing both Registration AND Vaccination in the Registration (big white) tent. Then, no second stop, straight to Observation. It was going so well, we recruited additional people to run a second line.

INSIDE the big tent. Four cars in a row. One stop to do it all. We don’t have all the timing numbers yet, but we believe this may take additional seconds or minutes out of our cycle time. There are some potential downsides to this configuration VERSUS our vaccine tent configuration; the registration workstations on wheels (WOWs) aren’t as nimble in traffic compared to our handhelds, so walking upstream when there is a delay is not practical, and if one car takes longer inside the tent, there is more potential delay. The upside: one stop could make the transit time much shorter per vehicle.

At the end of the weekend, ZERO DOSES WASTED. 10,000 given. ZERO significant complications in the observation area. Dr. Richard Zane calculates that the 10,000 vaccinated patients means that 157 fewer people will die of Covid as a result of our actions this weekend. Wow.

Stay tuned! We’re already performing at a high level, but we think there are yet improvements to make, while keeping patient and team safety our top priority. The work of our Incident Command structure has been a joy to watch, with team leads in constant communication with the Rockies, the Denver Police, the State, County and City.

Here’s a CBS Denver news article about us, with more photos from a drone.

CMIO’s take. Who knew that Toyota Lean Process could help vaccine administration? Furthermore, I’ll say it again: Get us more vaccine! We can handle it.

The Invite-Only Mass Vaccination Trial Run by UCHealth at Coors Field: an Insider’s Peek

Outdoor vaccine guy says: come along, I’ll show you what I learned.

Indoor vaccine guy dresses differently from Outdoor Vaccine guy

The UCHealth team held its first Mass Vaccination trial at Coors Field on Sunday 1/24. This was the first Mass Vaccine effort in Colorado, and was coordinated with the City and County of Denver, CDPHE (Colorado Department of Public Health and Environment), Denver Police, Verizon, Denver Health, Stadium Medical and the Governor’s Office. Weeks in the planning, dozens of clinicians, staff and coordinators swarmed the location assembling, arranging, tweaking.

2 hours: 1000 vaccines?

For this event, we planned to give 1000 vaccines in 2 hours to stress-test our design plan and to see if we could maintain or exceed this pace for future events. This was an invite-only event with 500 patients selected from UCHealth existing patients and 500 from newly-signed-up for vaccine from the UCHealth website for the general public aged 70+ per State current guidelines.

Between 6 and 7am, we assembled, got last-minute instructions for our many roles: runners, flaggers, registrars, traffic control, vaccinators, timers, process engineers, clinical observers, flow coordinators, etc etc. Here, I’m standing under a heat lamp, warming my hands for the day to come. The big white tent is registration-confirmation. Sorry, no drop-ins.

Team Number ONE!

With Dr. Jenny Bajaj, CMO of UCHealth Medical Group and Andrew Mariotti, medical student and process timer. We, of course, snagged Vaccine Tent #1. For work like this, snow pants recommended.

The UCHealth team set up a small batch of cars to arrive between 8 and 9am, to work out the kinks at every vaccine station; each station received 2-4 cars to test our supplies and workflow, and see if the runners, pharmacists, flaggers, observers had any questions about their jobs.

We then huddled between 9-10am to debrief questions from the team, then BOOM. Our full-speed test was from 10-12am with 1000 cars to come through in that time.

From the fourth floor of the Coors lot parking garage, the command center station. The RTD commuter trains run along the left, Blake Street on the right, the big white registration tent, where we catch and release any folks without appointment. The Mass Vaccine event (like EVERY Covid vaccine clinic) is highly calibrated down to our last vaccine. If we accepted drop-ins or family members, we would run out for our scheduled patients.

In the right row of tents, the first (most distant from us) tent is for registrations taking longer than usual, so that no registration line gets held up. Vaccine Tent 1 is thus the second (tiny) tent on the right. See me waving? No? No.

Our observation area (not shown) is actually behind the photographer, on the other side of the parking garage, with flaggers guiding the way.

Work station setup.

We re-arranged our area to be increasingly efficient. Working in teams of 2 allowed us to iteratively reduce our cycle time for each vaccination. Orange bucket 1: our vaccine supply (closely guarded by pharmacy and defrosted just-in-time). Orange bucket 2: pre-opened bandaids. Nothing is harder than cold, gloved hands opening bandaid packets when in a rush. Supply of gloves, alcohol swabs, gauze if needed. Raise the Yellow laminated card to indicate to runners if we needed supplies. Red card: help needed. Pink ribbon: attach to drivers side mirror for those warranting extended observation (eg previous history of anaphylaxis).

Workflow:

*One person waves down the car, checks “Please put it in Park!” (about 1/3 don’t unless asked!) asks the screening questions, confirms which arm, which passenger.
*Simultaneously, second person (vaccinator) doffs/dons gloves, opens alcohol swab, snags a pre-peeled bandaid, grabs a syringe
*Pivot! first person files the screening paper with identity and signatures for later data entry and grabs the vaccine card
*Simultaneously, vaccinator: Swab, Pre-attach 1/2 bandaid, Vaccinate in one motion, auto-retract needle (more on this below), Swipe bandaid across, Done!
*Pivot! first person explains the card, answers any questions, reinforces importance of second appointment, directs driver to proceed to next flagger to wait for the standard 15 minute observation time.
*Simultaneously, vaccinator disposes the syringe, clears trash, dons/doffs gloves and preps the next setup.

With this setup, Dr. Bajaj and I started with about a 90 second cycle time, and with iterative adjustments, pushed our best time down to 59 seconds, with our average running 1:15 to 1:20, if no questions (or profuse thankfulness) from the patients.

On debriefing this, we had several thoughts: the time it takes to chat and manage paper is about the same amount of time to swap gloves, manage supplies, setup. Seems like the 2-person team is, at present, an optimal setup.

In the coming weeks, it may be possible to incorporate a clinician-mobile-app adjunct to our Electronic Health Record that would allow on-the-fly documentation that would take the place of paper questionnaires and signatures when in the field.

Paper is fast, but…

From an informatics perspective, the paper process was a win from a through-put perspective, but an opportunity to streamline data-flow. We had runners taking our paper to the Documentation Tent to be keyed into the EHR in near-real-time.

Contrast that with our in-hospital based vaccine clinic (see my last post) where vaccination and documentation occur in real-time, the EHR and the State Vaccine Registry being updated almost immediately, and with a cycle-time (with one vaccinator/documentor) at about 3 minutes.

Teamwork. One step pivot, the choreographed dance of a one-minute vaccine cycle.

A “Fauci-Ouchie”

as my sister is fond of saying. At the end of our time, Vaccine Station 1 reported 67 vaccines given in 90 minutes. That is EIGHTY (80) seconds per shot. Taking into account the times when our station did not have a car, we think we could have completed 10-20% more shots. We are NOT Throwin’ Away OUR SHOT.

Here’s our high-level debrief. Team leaders from each of our major roles reported in: paramedics, police, City and County and State leaders, the Rockies (THANK YOU FOR OUR USE OF YOUR MASSIVE PARKING LOT AND TRAFFIC EXPERTISE). Very smooth. We think we could increase the pace beyond 1000 per 2 hours. We are targeting 5000 vaccines per day for 2 days next weekend. We’ll see!

Total throughput time per car?

Measured another way, we found that cars moved from Arrival at the Registration Tent to Leaving the 15-min Observation Area: 21-27 minutes. TOTAL.

Zero anaphylaxis events. No paramedic transports. There were very infrequent side effects observed in the observation lots. Everyone drove away successfully.

Local news coverage of our event

Sky9 aerial footage (about half way down the linked article). Tent 1 and my white coat is visible at 20 minutes. Woo!

https://www.9news.com/article/news/health/coronavirus/vaccine/uchealth-to-test-out-covid-19-vaccine-site-at-coors-field/73-96ede931-ad3a-45eb-8778-01de38562844

9News, Sky9 footage

Fox 31: https://kdvr.com/news/coronavirus/covid-19-vaccine/appointments-required-at-denver-mass-vaccination-site/

Denver Post: https://www.denverpost.com/2021/01/24/covid-vaccine-coors-field-drive-thru-clinic/

Denver Channel 7: https://www.thedenverchannel.com/news/local-news/uchealth-plans-to-test-run-mass-vaccination-event-at-coors-field

Auto-retracting needle?

Oh, and here’s a gif of the auto-retracting needle. So cool. How did they even fit a spring into the barrel of this tiny thing?

When done correctly, depressing the plunger completely means that the needle retracts from the patient, completely into the barrel of the syringe, eliminating the chance of unintentional needle-stick. Innovation FTW!

CMIO’s take? Mass Vaccination: another chance to innovate, another chance to take a chunk out of the Covid pandemic. Send us more vaccine. We can handle it.

A Good Covid Vaccination Is Like Calligraphy

Join CT on the front line of vaccine clinic at UCHealth!

Hi y’all! I volunteered for a vaccine shift. Me and a couple dozen of my best friends. Here’s the scene: this clinic day was dedicated to second-vaccine doses for nearly 1000 healthcare colleagues, 12 vaccinator stations, and a constant stream of patients down the hallway. Our location can handle 2-3x this number, if we had vaccine supply to do so (and on last Friday, our location and 9 other UCHealth vaccine locations dispensed over 5000 vaccine doses across UCHealth).

Having been a grateful recipient of both my shots, I’m ready to wade in and do my part as well.

Ever wonder what it is like to be a vaccinator at a high-volume vaccine clinic?

On the Vaccine Front Line

First, you receive an email to take your training on EHR documentation requirements ahead of time, and a super quick anatomy refresher on deltoid muscle and intramuscular injections. Easily done, about 10 minutes. Then you report for duty at one of the twice daily 7-hour shifts. You get a quick in-person briefing, some quick hand-holding (ok sounds weird in pandemic times), and off we go!

Here’s my station. Because, as my daughter says, I’m totally into ‘hume-optimizing’ (determining the optimal way for humans to do things – sometimes to the great annoyance of family members or colleagues: sorry y’all) I thought hard and asked lots of questions of my more experienced medical assistants and nurses sitting nearby. Here’s what I learned:

  • Card colors: Green card: hold in air when ready for another patient; Yellow card: running out of any supplies; Red card: medical question (just embarrassing to hold this one up if you’re a physician)
  • Computer: login, find the immunization clinic, filter out discharged patients, sort by time of arrival, click to remove word-wrap to show more patients per screen.
  • The data entry fields pull forward 80% of relevant data to each new patient, as well as the vaccine name, lot#, and details, and I’m down to just confirming patient identity, confirming injection site (6- R deltoid, 7-L deltoid: even the physical mapping makes it easy: when patient facing you, the 6 key is on the same side as the patient’s R arm!), asking the 3 screening Q.
  • Then the shot itself! Vaccine syringe (obvious) but don’t stick yourself or the patient unintentionally. (HOT TIP) And when you insert the needle, do it with a quick pop so that breaking the skin and finishing the motion are in the same moment and the patient’s sensory nerves don’t get a chance to register more than one ‘oh’ of surprise. Specifically, don’t be slow.
  • (HOT TIP from a PA colleague in Interventional Radiology) hold the syringe between your thumb and 3rd and 4th digits, with your index positioned over the plunger. Really? That’s the way? (Sooooo much faster than my jab, then switch hands, try not to be awkward, plunge, untangle my hands and pull back) and the jab+plunge was now less than a second. Level up! (Gamer talk). After my “technique improvement” lots of patients were surprised: “Hey! Didn’t feel that at all!”
https://www.jacksonsart.com/blog/2017/03/28/maggie-cross-chinese-painting/
  • (Irrelevant aside) I notice that this new syringe grasp is reminiscent of the way you are to hold a Chinese Calligraphy brush, like you are cupping an egg and then grasping the brush. Ah, such elegance.
  • (HOT TIP From a brilliant nurse colleague) After the alcohol swab of the deltoid, pre-attach half of the bandaid and let it hang down. That way, you know where to put the shot and you don’t lose track (if no spot of blood) of where it went as you look away to dispose of the syringe. Then flip the bandaid fully on, VOILA! Totally changed my life.
  • Click the needle protector closed with one finger, toss in Sharps container.
  • Mumble sweet nothings to your anxious client while doing the next steps. Answer any questions.
  • Type ‘n’ in the time field to get the time Now. Click Accept to complete the vaccine charting. Their patient portal account is automatically updated, and the State Vaccine Registry is updated (I believe either real-time or at midnight every night)! Add 15 minutes to write onto a sticky note to attach to their vaccine card for them to know when they can leave if feeling okay.
  • Reach for a tiny sticker to put on the vaccine card with vaccine name, lot#, date, location.
  • Smile with your eyes, gesture to the seating area.
  • (HOT TIP from another RN colleague): Wipe down: with gloves on, pull an antiseptic wipe for the desk, chair, relevant surfaces. Whip off gloves, rip and prep an alcohol swab and bandaid —easier with gloves off. New pair of gloves, position a new syringe on desk, check if running low on supplies, raise the green card.
  • NEXT! Cycle time when all was humming, as little as 3 minutes. Less time than it took to read this.

Of course, GEEZ some patients had the temerity to ask questions. Or we would briefly run low on vaccine as the pharmacy team whipped up another batch in the next room, or someone had to run for sticky notes or wipes or gloves etc. Or maybe I NEEDED A POTTY BREAK, OK? Other times, we would have lulls in the action. Then it was up to our green-card-waving skills as to which of a half dozen vaccinators the lone patient would walk to.

Here’s a counterintuitive tip for non-medical workers.

You might think that having your vaccine done by a person in green scrubs or a white coat (in my case, both) would be ideal: they’re the doctors or providers. In our organization, nurses wear dark blue scrubs, medical assistants wear dark purple (violet?). Almost uniformly, the docs volunteering haven’t given vaccinations since … medical school. In my case, 30+ years ago. My recommendation: go with blue or violet scrubs for technical proficiency and years of practice. Of course, if you want a long medical conversation, by all means stop by my booth!

Here’s my tally. Actually 55 by end of day. I figured out that I could keep my needle caps on the desk until I had a break to make my hash marks and throw out the caps. The system worked. I know many of my RN and MA partners were quicker than me or had better patient-attracting green-card-waving skills or took shorter breaks. Not bad for my first half-day shift.

This was unlike my daily work.

As a physician in an internal medicine clinic I would worry about how to reduce the blood sugar of an overweight, depressed and anxious diabetes patient with high blood pressure, severe arthritis, needing wheelchair repairs, a dozen prescription refills and several prior-authorization meds, and now with several new worrisome symptoms and family pressures. As CMIO I would worry about how to balance the anger of providers spending long hours writing notes and orders versus allowing a sloppy, error-prone verbal-order paper-like system. And how to allocate time and effort between reducing physician burnout and improving predictive algorithms when those projects were sometimes in conflict.

Working in a vaccine clinic by contrast was like playing a fun, fast-paced, team-based video game (not that I would know): clear goals, mutual reinforcement, visible progress, strong team camaraderie, repetitive (and improving) physical skills, opportunities for rapid learning, immediate positive feedback and customer appreciation, excitement over doing a public good. We were IN THE ZONE.

Honestly, on good days, both regular clinic and informatics work is like this too.

What’s not to like?

Oh, here’s one of our physician leaders, Dr. Andy Meacham, even with everything he knows about how docs are the worst vaccinators, willing to be my victim. Thank you for your service, Dr. Meacham.

Gratitude

Honestly, it humbles me to part of such an amazing organization that assembled the people, the process, the tools so that I could drop in as part of a well-oiled machine, only a couple weeks into this brand new process. I’ve noted quite a few physician leader colleagues also taking part. So cool. 

“Covid-19, Yes, Your Days are Numbered! We’ll take back our streets and those jobs you’ve plundered!” — CT Lin & his terrible (My Shot – Covid) ukulele song

If all this talk gets you interested in the vaccine, See my recent blog post on how to get in line for a vaccine at UCHealth

CMIO’s take? Serving as a Covid Vaccine vaccinator was one of the most gratifying things I’ve done. I’m signing up for more shifts. See you soon!