Webinar Transcript: How Seattle Cancer Care Alliance (SCCA) optimizes nursing capacity across multiple specialties and spaces

At a recent webinar presentation the Seattle Cancer Care Alliance, Angela Rodriguez, Associate Director of Clinical Operations and infusion nursing supervisor Rachel DuPree discussed how using the right nursing allocation software addressed the unique challenges presented by their care space, as well as their patient and staff populations. The transcript is below.

You can also view the whole webinar, or read a blog summary. 

Moderator: In this session, the Seattle Cancer Care Alliance Infusion Team will share several of the scheduling and staffing challenges they faced, stemming from the unique layout of their center, and their solution for maintaining a balanced infusion workload across multiple staff specialties and spaces. The goals of the webinar today are to share learnings and guidance from our two speakers, and to hear from webinar participants. 

I’m pleased to introduce the speakers from SCCA and would like to thank LeanTaaS for their sponsorship of this webinar. 

Our first speaker is Angela Rodriguez, the Associate Director of Clinical Operations at the Seattle Cancer Care Alliance, overseeing outpatient oncology infusion, clinical trials, acute evaluation, and hematology. She received her degree in Nursing from Winona State University and her Master’s degree in nursing from Hopkins in 2009. She’s been a nurse for 15 years, with experience in multiple specialties focusing on operational leadership for the last eight years. 

Rachel DuPree will be our second speaker. She works as the nursing supervisor in the infusion department at the SCCA. She also has experience as a hematology and oncology nurse, an outpatient infusion nurse, and as a charge nurse. Rachel works closely with the infusion charge nurses to develop patient care assignments that are safe and optimize nursing care. 

Emily Kowalski could not join us today. However, we’ll be in great hands with Angela and Rachel. Now I’d like to turn over the presentation to Angie.

Angela Rodriguez: Thank you, Nancy. Seattle Cancer Care Alliance is one of the only NCI-designated comprehensive cancer centers in the Pacific Northwest. It unites doctors from UW Medicine, Fred Hutch Research Center and Seattle Children’s Hospital. This network and partnership is aligned to delivering high quality and high value care to our patients, which also includes making the most of our resources and staff.

Our main clinic is headquartered in South Lake Union. However, our inpatient hospital is in Seattle’s university district up by the University of Washington campus. We do have an additional five community sites. There’s one not shown here as it just started, at Overlake, another eastern suburb of Seattle. 

Our infusion center here is actually split between multiple different floors. We have a total of 63 bays. This is a mixture of beds and chairs, and our rough patient volumes per day is about 140 to 160 Monday through Friday. and we’re averaging about 80 to 100 Saturday, Sunday, and holidays. Our daily staffing is adjusted to our patient volumes and so you do see a range here on the screen.

Our goal is to have a ratio of three patients per one nurse at any given time, which at the end of the shift usually equates to about six to eight patients per nurse per day. Our average length of stay per patient is between two and a half to three hours per segment. However we can have something as short as five minutes to something as long as 12 hours or more. 

Our main infusion center layout is the fifth floor here, shown for you. We do have the additional 10 bays on our fourth floor. This area is dedicated to our shorter infusions of two hours and less. On our fifth floor unit, which you see, we have a lot of long hallways and very odd corners. This has the potential of creating a patient safety issue for our nurses who might care for patients on multiple ends of the unit. 

Because of this we created subspecialties, which you see in the different colors here. These subspecialties help limit the distance that nurses might need to go in caring for patients, all at the same time. However it also does mean that nurses as well as support staff need to relocate themselves daily, based on the purple flex room usage that you see here. 

These subspecialties also have the potential to create some inequitable workloads. Our blue area is our solid tumor area. Generally this is a very chemotherapy-heavy area. Our pink area is more bone marrow transplant and hematology, which is very heavy with hydration and blood products. These much different demands on our nurses led to decreased staff satisfaction on our unit. 

We also have pretty unique scheduling practices. We have decentralized scheduling here at SCCA. This means we have over 50 schedulers throughout our institution that can actually schedule into our unit at any given moment. Different departments also have different needs. Solid tumor patients like to plan out their day a month at a time, and often schedule out a lot further, while our bone marrow transplant and hematology patients have more urgent scheduling needs and more frequently schedule within about a week or two. 

What we did is mirror our floor plan with different Epic templates to allow them to meet these different scheduling needs and not have capacity issues amongst each other, or tying up opportune times for different patient populations.

Also with the scheduling into subspecialties, there are times that this creates an issue with patient access or delays, and under or over utilizing our space on each side. Patients may also have limited bays to book into. We might see a schedule where there are hours in between their provider visit in the morning or lab visit, and their ability to get into our infusion area. What we have done to try to mitigate this is create a waitlist system. If there is a struggle with our many schedulers, or things are not optimal for our patients, we’ll have them put on a waitlist. Internal infusion schedulers will work this waitlist 24 to 48 hours prior to the appointments, to try to optimize the time, and decrease any waits for our patients. However, this actually does create some patient dissatisfaction, because they don’t really know their true schedule until a day or two prior to coming to see us. 

Here you can see the scheduling practices, as well our space utilization. So the pink area was our BMT and hematology area. Where you see in the red, where we’re often overcapacity into a lot of bays into that area. However, there are days where on our general oncology side, we have the capacity to absorb that. So when we looked at this, we really wanted to say, “Okay, where we’re under and over utilizing our space, how can we maybe combine this in a better way to help optimize it in the future?” 

So I’m handing off to Rachel here in just a minute to discuss our nursing assignment. We want to pause and check in to see if anybody has any questions.

Moderator: We have not had any questions come in yet, so we can go on to Rachel. But to all participating, please send your questions as soon as you have them. 

Rachel DuPree: What you’re seeing here is an example of an old RN assignment sheet. Previously, creating our nursing assignments was a manual process that couldn’t be easily adapted with people to new initiatives. Making the schedule for the next day was a four hour plus process with multiple people creating the schedule and editing it. There was one handwritten original schedule for each side or subspecialty. Because of the way the assignments were done, we would have to flex rooms, and keep nursing assignments overbooked. 

We were manually calculating nurses’ acuity hours to ensure that assignments weren’t too heavy and to see how many nurses we needed for each subspecialty side. We had to do this because we were stopping to the template and not overbooking. A morning sick call involved erasing the entire column, and then rewriting patient names, and then making new copies of the schedule for distribution. A lot of unnecessary work was required when we needed to make changes to the schedule throughout the day, for things like cancellations, urgent add-ons or late sick calls. The charge nurse had to alter their own copy, and then walk to the station where the original was located to update it, while notifying the RN of the change. They would then let our unit flow coordinator know so that they can update their copy, who would call the front desk to update their copy. 

Four separate schedules had to be manually altered for each change to a patient’s appointment. This was inefficient and there were multiple opportunities for communication breakdowns and errors. We knew something had to change with these inefficiencies. 

These were our initial goals. We wanted to improve staff satisfaction by balancing nurse workload; maintain and enhance patient safety by maintaining the co-location of RNs for their patients; and maximize patient access by optimizing physical space and providing timely access to minimize patient delays. 

Then COVID hit, and that brought even more challenges. We had to extend our hours of operation to seven to 10, seven days a week on our main unit, and also extend two extra hours in our short stay unit. We opened multiple new services to support our hospital decant. 

While we were planning to open an acute clinical evaluation clinic in July of this year, we had to move that up to March. This clinic was conceptualized to assist our patients with acute symptoms and reduce the chance of them needing to be seen in the ER. This goal became even more important with the onset of COVID and worries that ERs in Seattle would be overcapacity. 

New services like the COVID hotline and the testing centers required our triage and patient care expertise. There were increased staffing limitations because as an institution, we weren’t allowing anyone to come in with any symptoms whatsoever. So if you were having acute allergy symptoms you had to stay home. 

Any staff who were classified at-risk had to stay home and were removed from patient care. With increasing needs for social distancing we moved people to offsite locations, or they transitioned to work from home if they were doing administrative tasks. With these limitations, we were also training and pulling our staff to support these new services.

The same goals we had before were now more important than ever. We had to prioritize the ask of our staff, knowing we were entering a time of rapid change, and likely anxiety with the pandemic. We knew we were moving inpatient protocols outpatient, and we had to open new services. Things were also rapidly changing with COVID, requiring new PPE and new schedules. 

There were increased staffing limitations. Remember, we had no additional staffing and the extension of hours meant we had to stretch existing staff. We asked ourselves, “What problems do we try to solve now? What may need to wait? Is addressing the level loading important enough to address now, and how will it help us?” We decided to move forward to help level acuity and to create more free time that can be allocated to patient care, or other new services.

How we needed to prepare our staff changed over the course of the year and the pandemic. We expect it to continue to change. We started out with our infusion team, being the response team to go to the patient wherever they were for testing via the clinic room, or an infusion bay. As this pandemic grew, we had to expand with an institutional response. There needed to be a huge partnership with all teams, departments, and disciplines. 

Some of our initiatives included front door screening for symptoms. We set up two Testing Centers, one that was walk-up and in the clinic building and one that was drive-up. We started a COVID triage hotline for anyone to call with questions from 8am to 10pm daily. We were the first epicenter in the US for the pandemic and we were even getting calls from Kentucky. 

There needed to be movement of inpatient protocols including regimens like EPOCH, AIM, HYPER-CVAD, and GCLAM — we needed to move those to the outpatient setting. This required us to prepare clinic and infusion staff with new knowledge and education around these protocols. We also opened the acute clinical evaluation unit to decant the ER. We knew during this time we needed to be agile and flexible, because we didn’t know what additional changes were coming our way. We decided to implement the nurse allocation tool using iQueue. 

What you’re seeing here is the iQueue view when you’re inputting the nurse names and their start and stop times. The departments self-schedule into separate Epic templates, but iQueue mixes or pools these appointments into one unit. Our RNs are divided into pods so they are co-located with their patients, and transfusions and hydrations are mixed more evenly with heavier chemo regimens across the unit. Our flex rooms are no longer necessary, and our support staff have an even workload.

So this is the Gantt view, or what iQueue looks like after you run the RN allocation. Our nurse allocation in iQueue reduced the time we were spending on our nursing assignments and allows us to make real time adjustments. It now takes 30 minutes or less to make the nursing assignment for the next day. Previously it took four hours. 

The Gantt view helps visualize the nursing assignments throughout the day and pass offs can be easily identified. And this real time data allows transparency and a more accurate grasp of the current status.

Here’s a reminder of what our layout looked like before. This is what didn’t work for us. Angie talked about how it was divided between heme and genoc, and then we had both purple flex rooms there in the middle that weren’t working so well either. So these shows are the pooling and Epic schedule, along with using iQueue and altering our layouts, allow for greater utilization of space without us being over capacity. We lost those purple flex rooms, and that yellow down there is the addition of our ACE clinic. 

This is another reminder of how we were often overbooked on one side, and we had room on another, because we were scheduling into subspecialties versus pooling it all together and breaking it apart. This shows how pooling Epic schedules and iQueue, along with altering our floor plan allowed us to use our space better and not go over capacity.

We decided we needed to engage with our staff more to figure out how else we could help. We now use multiple modes of communication to ask them for ideas and ways we can increase our efficiency. One suggestion was to move the daily schedule online. We were originally still attached to the idea of having printed copies of the schedule, so we were downloading the schedule from iQueue into an Excel document and printing those to place to all the nursing stations. We then moved to uploading the downloaded copy of the schedule to Microsoft Teams, so that it can be viewed by many people at one time. This eliminates the need for the charge RN to alter multiple copies of a paper schedule throughout the day, to bring them up. To help in other ways, there are fewer opportunities for communication breakdowns and the offsite staff are able to access the schedule as needed as well. Most importantly the schedule is not only located in one central place. 

I want to pause to see if anyone has any questions at this point before moving on to Angie so she can discuss the later impacts of COVID on our capacity and where we are at now.

Moderator: We have two questions. The first is, what are the hours and days of the week of your urgent clinic? 

AR: Our acute evaluation clinic actually mirrors the hours of operation of our infusion center, so it was open from 8am to 10pm. I’ll discuss that we later retracted that back. Currently it is 10am to 10pm Monday through Friday, and 8am to 6pm on Saturday and Sunday.

Moderator: I think you just answered the next question, which was hours of operation in your regular infusion center, and if you operate on Saturdays. 

AR: Yeah, we do operate on Saturdays and Sundays from 8 to 6, and holidays are the same.

Moderator: Thank you. I think we can go on and see if we have similar questions when you finish up. 

AR: Like many organizations throughout the United States and around the world, we definitely see the later impacts of COVID on our operation. Here at SCCA we’ve seen approximately a 20% decline in our infusion visits. However, some of this was intentional. Many of our clinics shut down to new patient appointments, as well as deferred new chemotherapy starts, because we didn’t know how COVID-19 would impact our immunocompromised patients.

We did continue to see those that were currently on treatment. However, the idea was to protect those that were not already immunocompromised and to delay what we could. So we erred on the side of caution initially, during the first wave of COVID here in Seattle. 

As we worked throughout the year, we knew it was definitely not sustainable for us to keep deferring these visits. We also knew COVID-19 was not going to be going away anytime soon. So, this summer, our clinics began to open again to new patients, as well as enrollment in bone marrow transplant. As you see on the right hand side here, we were anticipating what we call the post-COVID surge, so all the deferred volume before, or those that might have just delayed their chemotherapy starts. We anticipated we were going to see something beyond what our capacity could handle as we’d seen this surge back to the healthcare facility. 

However, we anticipated that for us to be able to see a lot of these new patient visits, it was going to take eight to 10 weeks or more with our current capacity limitations. What we decided to do from an institutional recovery plan was actually to look at how we can open more peak hour capacity, because we know our patients absolutely want to come during our peak hours. Here at Seattle Cancer Care Alliance our peak hours are generally 10am to about 4 or 5pm. We partnered with our clinics and opened up our new GI care neighborhood, which is part position clinics and part infusion within that same area, to hopefully open up some more capacity.

We also looked at where we had underutilized space, and where we were underutilizing our staff. When we first planned with COVID we extended all of our hours, to 7am to 10pm, every single day of the week. So we looked at, “Okay, what hours are we really not seeing that many patients that we anticipated, where can we cut this back?” 

Here you see we delayed our opening of our ACE clinic from 8am to 10am, because we really hardly see any patients prior to 10am. We also developed floating processes with our other infusion areas to try to make sure that if there were any sick calls, we can optimize our staffing to deliver high quality patient care, and make sure our patient needs were met throughout the organization. 

We also shortened our short stay unit back to 8:30 to 6:30. We have previously extended those extra two hours in the evening, as well as shortened our weekend hours. We did implement a multi-departmental huddle in the morning and in the evening, to help anticipate if there were any staffing needs for the next day or even patient needs, if we would need to transfer as many units close at different times throughout the organization. 

I will say this. Our staff have been super resilient this year and I’m sure many of you have seen that as well throughout your own organizations. We have found our staff has also been incredibly flexible during this time. However, you know, when COVID-19 first hit us we thought, okay, this is going to hopefully last a couple months and we’ll be through this. Now, I think all of us understand this is not really going away anytime soon. We have to look at what is the long term sustainability of our staff, and the many asks that we put on them. 

So we do regular check-ins with our staff and rounding, we ask them for ongoing feedback about how things are going, how they’re doing with floating to many different areas in support of these ongoing initiatives, and making sure we’re meeting them where they’re at, as well giving them a break if they need a break. We also encourage them to use some vacation time and personal time if they need to, as we all know everybody’s anxiety levels and stress levels have definitely been at an all time high throughout this entire year. 

We will say that our staff truly have been our greatest strength this year. They have been absolutely amazing with the feedback that they’ve provided us and ongoing thought of what else can we be doing to improve patient care, the processes as well as being mindful financially of how we’re doing and how we’re operating, but the teamwork they’ve also shown and their adaptability has truly been amazing. 

With all this in mind, here’s where we’re at six months after we were the episode of the first epicenter of the United States here. We’re still maintaining our original goals of maximizing our patient access and ensuring any oncology patients are able to get timely care. We also want to make sure we’re maintaining and enhancing our patient safety. So we’re always adapting our testing procedures and surveillance testing for certain populations, to make sure that everybody is safe to be here. We want to make sure we’re limiting visitors as well during this time just for limiting exposure, as well as maintaining and improving our staff satisfaction knowing where they’re at. 

Most importantly, with the wave of this year and the roller coaster that it’s been, we really are looking at what is, and how can we be, sustainable long term. This does mean keeping in mind matching our operations and being flexible to our operations with our new patient demands, whether that means tightening or lengthening our hours of operation based on what we see this year, and revising our patients scheduling, ensuring timely access for them. 

Most importantly too, we’re looking at our financial sustainability and stewardship, keeping in mind how we maintain the bottom line here and ensuring that we’re doing the best that we can with the resources and the space we have. 

We still have maintained our inpatient protocols as outpatient. We’ve actually found with that one, our patients actually prefer to remain outpatient. We’ve definitely flexed our staff in different ways to help us keep being mindful of this.

Thinking back on this year and all the process improvements, we definitely have gained some pearls of wisdom.

RD: We initially thought that we should delay the nurse allocation tool roll out. We were worried this change would be too much along with other pandemic related challenges. However, we are glad we followed our gut instinct, as this has greatly assisted us during this crazy year. It’s given us more flexibility and time that can be directed at patient care instead of manual schedule making.

AR: Not only were we able to achieve our original goals of better utilization, and ensuring level loading of patient acuity for our nurses, but we were also able to save time with many efficiencies that were completed this year. This also set us up for more flexible staffing and more flexible scheduling for any other unforeseen needs in the future, like changing our operating hours, our staffing models, as well as adjusting to just frequent volume changes as we’re opening other units during this time. 

One of the other big things as well: this presentation was geared at what we’ve done here at infusion. I do want to point out that a lot of these changes were partnerships with everybody throughout our organization. Even with front door screening, our Chief Nursing Officer was out of the front helping screen patients, and we really all came together. I want to acknowledge everybody here at SCCA partnering throughout the craziness of this year, and all of our changes as well in their impacts to other departments. We have a slogan here at Seattle Cancer Care Alliance of “Better Together”. That just could not be more true than it has been this year. 

We wanted to relay our contact information as well to you guys if there are any additional questions or follow up that you would like to do with any of us after this presentation is done.

Moderator: Thank you, we did have another question and I have one or two things I was hoping maybe you could speak to, from your experience. 

The first question was, will this be recorded to view later? The answer to that is yes, via the ACE Members only section of the website of the organization and the ACE YouTube channel. [This is also available from LeanTaaS website.] 

We also want to know about limiting visitors within the facility. We all know most of these patients come with someone who sits with them or helps them get from the front door to upstairs, and takes them back out. You mentioned initially your extension of hours at the beginning of the COVID outbreak. When you look at staff time, to be able to help patients get up, in, out and back out, how did that impact your schedule?

AR: So one of the shifts we did make, is that our nursing assistants actually used to courier medications from pharmacy to the nursing unit. The nurses then would carry them basically from mixes to the patient rooms. We reallocated that currier work to the pharmacy technicians and other couriers throughout the organization, to free up more nursing assistants to help with any patient care needs on the units themselves. So if patients needed more assistance getting up and going to the bathroom, or if they needed any assistance with food or beverages, we had more nursing assistant staff available to help them during this time. 

We did limit visitors, but we did not exclude visitors. We did ask that one visitor be here with a patient at a maximum, and it was mainly so we can help social distance. But we know that, especially in oncology care, having a caregiver with them is very important to our patients’ mental health and support system during this trying time.

Moderator: Another question that’s come up, I think, on every one of our webinars, is what you did about break rooms? 

AR: So our facilities have been amazing.  One, we can’t have any more in person meetings, everything has gone to Zoom or virtual for the most part, especially at this stage in the game. But all of our previous conference rooms have actually been made into staff break rooms at this point. So we have additional room for them to spread out and have those breaks. 

We also did move some providers off campus here in the clinic building into other buildings, which freed up some other office space. We made that into quiet rooms, so if any of our staff needed to take a 10 minute break, to take off their masks and/or face shields for the day, and they just needed one of those breaks, we have those that are reservable for our staff to use. Anybody can reserve those rooms.

Moderator: Thank you, great thoughts. Question: “Don’t know what’s going on in Seattle, but wanted to know if in the planning work that you’re doing, if you’ve had to make any adjustments related to distance learning for children of your staff. In other words, time at home.” 

AR: So, for us here in Infusion, I would say yes and no. We’re definitely working with our staff that need more flexible schedules, to align with, maybe, when they don’t have additional support at home. We try to work with them to help them with those daycare concerns and virtual school. 

Many of our staff that have been able to convert to work from home, like administrative staff, have been relocated to home to help support that. We do require our staff to have somebody there to assist with childcare, even if their children are too young, in the sense of, you know, you’re definitely not as efficient trying to work when you have little ones that also want your attention. We try to balance giving them an option to work from home but also realizing that additional support is needed for them to still be effective and productive for work.

Moderator: Thank you. We’ve had another question come in. “This statement is not necessarily a COVID-related question, however, do you have a triage-type nurse that ensures the patient is chair-ready for treatment? For example, blood draws, port access, IV access, etc.?” 

AR: Our patient flow is a little bit different, we have a few different things in place. Our lab is staffed with LPNs and RNs, as well as phlebotomists, so they will often access ports for us. If the patient does have a port or start IVs for many of our medications, besides vesicants, and ensure access is done that way. Many of our patients also have central lines here, with the long term care treatments that they need. So I would say, much of that access is already solidified before they come to us. 

We do have a nurse that preps our schedule and reviews orders, ensuring that everything is ready to go, the patient had a lab appointment scheduled, their lab was drawn, their orders are in, their orders are signed, everything is ready to go for today’s treatment. That nurse, we call that our chart review nurse, is working about two hours or more ahead of the schedule every day, and preps for a little bit for the next day. We do have that in place to try to expedite what we can for our patients as soon as they come here. 

Many of our patients do, I would say, about 65% to 70% see their providers on the same day of coming to Infusion. So many of them are linked, and some providers do prefer to sign orders when they’re seeing the patient, which has the potential of delaying things if they forget. So that chart review nurse is really there also to help us catch and expedite those things to make sure any of those issues are resolved prior to the patient coming through infusion. 

We also do have a triage nurse that does after hours and weekend triage. This is more a telephone triage. Patients call with a concern or a symptom issue. Our nurses will either bring them into our ACE clinic for evaluations and then to the emergency department, or be able to resolve any issues over the phone. We welcome that as a method for our patients as well.

Moderator: Have you had to deal with, at some of the large, not only large centers, but all centers, someone who inadvertently gets into the facility and is COVID positive? 

Angela: We had patients that have decided to walk up the stairs in our garage and bypass our screening. We have had the occasional one of those. However, we do have identifiers on people. If they have been successfully screened at our front door, we do have white stickers that say “I have been screened” and whatever day of the week it is. Often if a patient does happen to bypass — now we’ve locked down the stairwells from our garage, or at least, people are unable to bypass without being noticed since that even — but If you check in at any of our front desks, and they do not have an “I’ve been screened” sticker, our front desk can conduct that screening, as well. 

Our COVID positive patients that are known to us — I will say our patients have been really great about alerting us that they’ve tested positive at another community center, but those that are known to us, we will actually have them wait in their car, call us, have them escorted to whatever the last appointment is for the day, which is often us here at Infusion, and have all services brought to them in that one room. 

Basically, if they’re just here for labs and their provider visit, they will go into a designated room in our clinic area, and all the services will go to them in that room. But they’re escorted through the building to that room, so we can ensure the footprint of what has been potentially touched or contaminated and make sure that we’re limiting exposure to everybody else.

Moderator: Last question: any words of wisdom, as people in the US look towards the fall and the potential for flu and COVID, are there any other things you all are doing or thinking about that you haven’t already addressed relative to going forward? 

AR: I would honestly say, in the fall here in Seattle, we always have a pretty bad respiratory season in the fall. We are anticipating, if we do get the dual surge of flu and COVID, it’ll most likely hit us sometime in October. We’re definitely prepping for a lot of that. While we may have kind of relaxed a little bit on testing guidelines this summer, we started kind of ramping up again and testing for more procedures this fall. 

We did institute face shields and face protection for our staff during any patient interaction, not just those with COVID or droplet precautions, but all patient interactions, as well as offering it to our front desk staff. 

Our infection prevention specialists we have here are completely on top of the CDC and WHO recommendations, and also jointly partner with UW Medicine and Fred Hutch, with the research they’re doing as well as their practices in their organization, so we can all align, making sure if our patients go back and forth between facilities that they’re experiencing the same expectation from their end as well. 

We definitely are anticipating something to come towards us this fall. However, as a lot of the same stuff that we have been doing — making sure we remain diligent on wearing proper PPE, hand hygiene, ensuring people stay home if they’re sick, and also ensuring our staff stay at home if they’re sick or have any symptoms whatsoever — just to try to help protect everybody that we can.

Moderator: Angela and Rachel, thank you so much for a very informative webinar. I’d like to thank all the participants here today.