Edge Talks November 2016: Fixing Patient Flow Transcript
I am hoping you will be able to use the chat room to tell us what you think about the area, and also,
use #EdgeTalks on twitter to let us know about what you think about flow.
I am your host for today, and Dominic will be supporting in the chat room. Please use the chat box to
contribute, and also tweet using the hash tag, #EdgeTalks.
This is me, Janet Wildman, and Dom Cushnan here.
We have been working with Sasha since June this year and he's a fantastic guy to work with. I have
worked closely with him on a number of projects, and he has been a member of the Nuffield Trust, and
has had a recent publication, "Understanding patient flow in hospitals." I am looking forward to hearing
more about that.
He has held a number of senior positions and will tell us more about tackling the complex issue that
we are faced with today around patient flow. So, we will be looking at the recent Nuffield Trust report,
looking at decision-making and complex environment, and what to do when data doesn't fit.
So, I will hand over to Sasha and take it from there.
Good morning, everybody. It is a pleasure to be here talking about this topic.
I found this first picture from a jigsaw. I think this is good in understanding flow, and I will take some
time in understanding why. If looking for Christmas presents, this is a great place to start.
I have been involved with flow for a long time and have been trying to understand the challenges. I
have been working with colleagues to stand back and have a look, and I want to talk through that
experience, hoping that I trigger some useful ideas.
So, understanding patient flow in hospitals is what this is about, and I want to highlight a couple of
pieces that are likely to be published soon, in particular the health foundation and what they are doing.
I will look a bit at whole systems, but most of today's talk is about the in-hospital part. This is where the
major constraint is.
I want to start here, and one of the first things I did when I started with the Nuffield Trust was look at
the four hour standard. In 2014/15, the top 12 trusts breached 4.2% of the type, so they were
achieving just over 95%, and those furthest from this type had a breach rate of almost 18%.
The differences are quite interesting. Those trusts that are furthest from the target are almost twice as
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big as those hitting it, and length of stay was only 0.3 hours. It probably only boils down to that, and
solving that solved the problem of flow.
So, we looked wider at what was happening in the system, and you can see some interesting
differences. Those achieving the target by using more beds per person as opposed to those who
aren't, and they have a higher admission rate which is slightly counterintuitive, and more space
available at midnight.
This got us thinking about those differences and what we could learn from them. So, we will tell you a
bit more about that.
So, one of the big challenges when in your individual hospital at any point in the system is trying to
understand the perspective, and I thought I would illustrate this with a picture. This is part of a mosaic
tapestry, and I'm sure none of you can work out what the picture is, but if you stand back a little bit,
you can see who that is. It is actually Desmond Tutu.
I think this illustrates the problem of needing to bring together information and ideas from lots and lots
of different parts of the system, and to do that in a very nonhierarchical way. Bits of information are not
more important than other parts of the story. What is critical is to build a whole picture of what is
happening to inform what action can be taken, and I feel that very strongly, and we will talk about that
more as we go along.
What I want to say about the data is that most of it has originated from stories, so I firmly believe in the
management by walking about, trying to improve flow in hospitals by talking to people at lots of
different points in the system to understand their perspective. That is tremendously powerful, and then
starting to add numbers to inform those stories, bringing the different parts together. I hope that gives
a rich picture, and we will talk more about that as we go on.
The work we have done in the Nuffield trust links together with other pieces of work that were recently
published. This paper was brought to my attention recently, and instantly, you can start to see that
there are lots of ingredients to get right.
I will start off by looking at this for today's talk, taking those things out of order. I will talk about
population, capacity and process.
Firstly, the population is changing. This chart just shows the likelihood of spending time in hospital,
and it's no surprise that the older we get, the longer we spent in hospital. It is quite profound. Most of
us involved in this call today are probably likely to be spending no more than half a day on average in
hospital per year, yet by the time you reach 85, the average is just under a week per person per year.
Over the last six years, there have been small improvements, so people are spending slightly less time
in hospital, but when you look at this chart in relation to future population change, you can start to see
a potential problem.
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This chart shows that. What this shows is that, on the left-hand side, the number of beds that are used
across the country in relation to age, so eventually, there are about 10,000 beds for people up to about
14, ranging up to just over 100,000 for the total population.
By 2020, there is an increase, and by 2030, a bigger increase, leading us to about 140,000 beds if we
continue working where we are today.
That is a big change, and the question is, can we optimise our current systems to deal with that
increase, or do we have to change the fundamental models we are operating with? We will discuss
that as we go on.
Someone has put in the chat box, this is largely a result of the post-war baby boom. By 2030, that
group are increasing massively, and that will have a big impact on what we do.
This underlies one of the key problems that are facing us at the moment, so people were routinely
hitting the four hour standard in 2011, by 2014, they weren't.
That use has been increasing and the number of beds available has been pretty flat. I think that
creates a constraint, with more people trying to fit through a narrow gap, and we will talk more about
that in just a moment.
What is interesting is that that use is partly driven by population, and as the system gets more
ingested, it takes longer to be treated, which is a double whammy.
The classic question, which line would you like to change and which line can you change? We can say
that we would like more beds, but is that possible? We have to train staff to work and operate all of
those beds, which is also not that easy to achieve.
In reality, we need to think much more about how we use the capacity that we have got.
I want to use a picture to illustrate this, and we will all be very familiar with this picture. It tells us a lot
about the problems that we are facing in hospitals. Firstly, that the design of the motorways has been
remarkably stable for a long time, and typically they have three lanes. You can see a recent innovation
of a managed motorway where we have bought the hard shoulder into use. It is tempting to say it is
the extra cars that are causing the problem, and it is tempting to say it is the lorries that our problem.
In reality, it is the interaction of all of the traffic in a particular situation.
We need to think about that.
I then thought I would illustrate some of the concepts of flow, putting a few numbers to this picture.
Those who have read the report will have seen these numbers before.
The left-hand lane is travelling slower than the right-hand lane, and there is variation across the lanes.
The fastest driver complying with a 70 mile an hour limit should take about 28 seconds to cover a
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This goes up from taking 28 seconds to cover a km to 37 seconds. As you get up to heavy congestion,
you can see the number of vehicles in a kilometre obviously increases massively as does the journey
time. This is really illustrative of some of the problems. If you imagine a congested emergency
department and think through the amount of time it takes to care for the patients in a free-flowing
situation, it might be around 28 minutes, and in this illustration, it is nearly 7 times more by the time
you get a heavily congested situation, so the workload in a constrained area massively increases. As
we all know, it is massively more stressful driving in those situations, so we have to think also about
what kind of environment we are creating for people to work in, and more importantly, to be cared for.
Let's try and apply that to a problem we are dealing with daily.
I want to talk about it in these terms. How do we better measure and manage flow? What can we do to
transform the way we look after people, and to what extent can we avoid the need for people to travel
through the system?
Starting off with a chart of occupancy across the country. It is relatively complex. You can see, we can
week, the pattern of activity is pretty similar. You can see that over the summer the level of activity
drops. You can see a massive fall on Christmas Eve when virtually nobody is left in hospital, and you
can see the winter period over to the right just after Christmas.
The red line in the middle of the chart with a couple of little steps in it is the number of beds recorded
as available across the country.
The dashed line right at the top of the chart is the number of beds you would have required in 2014/15
if you decided to apply the 85% rule. You can see at that level, there would be enough beds for all
sorts of situations. You can also see a huge number of white space above the number of beds we
actually use, which suggests we would have a huge amount of spare capacity for much of the year, if
we use that rule. There is a judgement between the number of beds being used and the old, if you like,
rule of 85% – where do you draw that line?
The other important point is, should we be planning to merely cope, or should we be planning to
maintain a consistent level of service? In many other walks of life, we as consumers expect to get the
same standard of service pretty much whatever we want to consume it, and why should hospitals and
healthcare be different? We need to be building insufficient resilience to cope not just today, but next
month and next year to make sure the quality of the experience is high.
The other point to note – this is really important – we used to measure and still measure hospital
occupancy at midnight. In the old days when matron went round admit night and checked everybody
was in bed, that probably made sense, but since then, we have massively increased a surgery on the
day of admission surgery, the amount of emergencies and emergency patients spending less than a
night in hospital has increased massively, yet we haven't change the measurement standard. I want to
talk a little bit about that in a moment. But just to say that floor planning, actually plotting the data over
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a year, and ideally even longer, will give you useful information. It is an important discipline of being
able to visualise what is happening, as opposed to just seeing data on a spreadsheet.
This chart takes it further and looks at bed occupancy during a day across a couple of month periods
where it is smooth data looking at each day of the week across a two-month period.
You start off with… The zero is the bed occupancy at midnight, what you would normally see if you
look at hospital occupancy. I have calculator this to say an increase in bed occupancy is a negative
thing because we need usually to find more beds, so you can see between midnight, which is zero on
the chart, and eight in the morning, occupancy in most hospitals increases. It is actually worse on a
Friday and Saturday night for not massively surprising reasons.
There is a net reduction in occupancy from 9 AM. By six, seven in the evening, is the lowest point of
occupancy. If you walked into most emergency departments, I think you would be surprised by that
because that is when the biggest queues happen. What is happening? We will come to that.
One of the key points of this chart is to differentiate between the idea of the occupancy, which is
actually not when most of the flows happening, and the notion of peak flow. Peak flow is when the
grass is almost vertical, so lots of people moving each hour, compared to when the graph is almost
horizontally flat when virtually no movement is happening, or net movement, in the hospital. You can
see a big difference between the weekdays and weekends in this particular hospital. In fact, over the
weekends, there is no net improvement in occupancy over the weekend. That is in many cases a
What happens when the system is not designed to deal with the flow rate? This charter tries to explain
that. What you have is, on the top line, the flow rate per hour, so you can see that at four or 5 AM, just
under 2% of the day's work per hour is happening, compared to 5, 6 o'clock in the evening, when
nearly all of the activities happening. And so just to see what happens, this chart then said, what
happens if we designed this system so that only 5.5% of the day's work and be done in an hour? This
applies particular to things like hotel services potentially, how many doctors you have in the system,
potentially how well resourced your radiology department is, but this chart is not specific.
What you can see is, if there is 5.5% supply and demand any 8%, somewhere around 6 PM, you have
nearly 10% of the day's work waiting. That starts to resolve somewhere around 8 PM, but there is still
4% of work waiting at 11 PM.
We have ended up with a big queue. If you think of the work rate at around 5.5% per hour, you are
adding almost 2 hours to patients' waiting time.
The interesting thing to say about this is it is not just about the beds. You could have beds. You just
cannot get people to them. It is a little bit like the motorway situation when you get stuck in a traffic
jam, and then you find an empty road and you wonder what it is all about. This is the same. There may
be beds at the end of the system, but because we have not matched the internal flow through the
hospital, you cannot get to them. We will talk a little bit about that now.
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This is a slightly retarded point, but does your bed change to look like this? I defy anybody to stick into
the chat box that theirs does. There is remarkably little data about what happens during the day, how
long does it take to get a bed ready for the next patient, how long does it take to move a patient. One
of the big challenges we have is that actually the systems we use in small hospitals and big hospitals
are remarkably similar. I quite often like to test whether something appears sensible in one situation, is
sensible when you look at it in a different place. Just imagine the twice-daily landings meetings at
Heathrow airport where at 8 o'clock we have about 500 planes arriving today, and it will be checked
what will happen at 2 PM, and see how it goes.
Where you have a lot of movement, the need for real-time coordination increases substantially, and
the ability to save only a few seconds and a few minutes matters a lot. How do you choreograph the
interaction between teams in the hospital? It is an easy question to ask. It is difficult to do in practice.
These sorts of interactions might be one of the ways we can at least make our existing systems work a
lot better, and should be an awful lot easier to do than just building more beds.
This does not have to be difficult. As I said when I started, lots of the information in this report has
come from talking to people about their experience and trying to piece the individual parts together. A
lesson I learnt a few years ago about how do you run an airline? They all have control centres and the
interesting thing about them is they do not try and build one big computer system, they basically say
the individual types of aircraft must have train crews to fly them. If you're flying 737's, you don't have to
know much about 787's. If you're running a crew in London, you do not have to know about what's
happening in Manchester. You coordinate between them. I think that starting to think about what each
of your individual teams knows and how you can bring that information together in a more structured
and real-time way take you quite a long way forward, but if you can move to real-time data, particularly
where there is a lot of movement, it will help massively. I will explain a little more about that in a
One of the challenges of why this is important is actually that average length of stay is a varied
measure of planning flow through hospitals. We are now in a situation where 58% of activity is zero
That is clearly a mistake because people have been through and left. It is like measuring traffic over
the Avon Bridge on the M5. If you measure it in the afternoon, it is very different to two o'clock in the
You have to work out how much the zero day patients are using. In this report, we assume it is 12
hours because there is no national recorded data. It is probably a lot less than that, but one thing that
has changed more is the volume of zero day patients.
Zero day activity increased over six years, and unless you have matched that, it is highly unlikely you
will end up with the same thing.
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At the other end of the extreme, only 10% of patients now stay in hospital over seven days. They use
65% of the beds. Going back to the motorway analogy, when I talked about motorway traffic varying,
this is a much greater variation. Those patients typically spend 30 something days, see you are
looking at 50 to 60 fold variation, and that has huge impact on what is happening.
Very easy to think we can go back to where we have come from, and I would caution against that. A
lot of the reasons that have driven as to day surgeries, units, bringing people into hospital to get the
right kind of diagnostic and interpretive skills are not that easily removed.
For example, we created something to speed the process up, but also, to manage the directive. We
introduced day surgery to improve the quality of experience and to free up beds. All of these changes
have been made to improve efficiency and effectiveness of the system, but they come to a point when
they create new constraints, so we need to think about new solutions to problems, and I just think that
we can re-engineer the past.
One key point of this talk is that we need to not look in the rearview mirror. We need to look at novel
solutions that deal with the current problem, but also take account of the problem we will have in the
future because the population is continuing to change. We are taking a medium- to long-term view as
we make decisions.
One of the big challenges is that people say it is all about getting people out into nursing and
residential care, as well as getting the same amount of domiciliary care.
This chart looks at people who were discharged, and there's been a 30% increase and length of stay
has increased. We're not making sufficient progress to keep the system imbalance.
When you compare that that increase to, for example, the space required for the zero day patients, it is
not that far removed, and when you compare it to the likely increase of bed increase, that looks to be
about 6,500 beds over the period that this report is based on.
So, as fast as we are improving, other pressures are moving in the other direction, and that is one of
the problems of our planning mindset. We hope we can improve from where we are, but we don't
always wait sufficiently with the countervailing forces.
So, before I come to solutions, I just wanted to pick up on a few thoughts. This challenge that we are
all dealing with now to improve flow has emerged over a three- or four-year period, and we are only
just starting to get a really good grip on what is going on.
I would argue that our approach to problem-solving has contributed to that. This is a picture of the
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constitutional court in South Africa, and for those who have been to Johannesburg and seen this
building, you will know it is a very powerful piece of architecture.
The picture on the right hand side illustrates the atrium, as the big pillars that other men to replicate
palm trees and the African story of, if you have a problem, sitting under a tree to think about it.
Sometimes I can take quite a long time. Actually, sitting and talking, discussing, are really important
parts of problem-solving, but doing it from a qualitative point of you without bringing some data to the
discussion is not a good way of doing things, so balancing storytelling with data is something I would
The second part is listening and thinking in a structured way, and this is very illustrative of that. The
windows you can see just behind where the judges are sitting, and those are symbolic. It is there to act
as the public, telling us something important about the transparency of the process, reaching a
consensus as a group.
So, when we have these complex problems, thinking a lot about the decision-making environment and
how to make it as nonhierarchical as possible offers real opportunities for speeding up the decision-
Just moving onto that and what else is a problem. When Nigel Edwards and I started looking at flow,
one of the key quotes was that the current data doesn't describe the problem. That can mean that the
data is wrong, but also, that the environment is changing. So, I think we have to use all of our senses
to solve a problem like this, checking that the data is telling you what you think, but if it isn't, it is not
time to sit back. It is time to think about how we can get new data.
Intuition is important, and one of the key messages from this piece of work is that lots of individuals
had key parts of the jigsaw but not the whole picture. The challenge of leadership is to build that whole
picture in a way that gets appropriate action to happen.
What the story does tell us is that the environment is changing. Over the last few years, death rate has
been declining in the country, and it's now predicted to increase over a very long period. A lot of the
past expectations of continual improvement need to change, and when you get those inflections in
data, it is usually sign of the significant environmental shift, which means that planning assumptions
looking backwards won't help very much.
This takes us to the latest news. We contributed to this work, but yesterday, the House of Commons
health committee issued its latest report on winter pressures, and one of their conclusions is really
important, that the response is to focus both on managing the patient's journey through the hospital
and in addressing the increasingly inadequate provision of adult social care services available to
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enable safe discharge.
I think the key here is that we need to be doing both, so most likely, the best strategies, I think, are to
improve data collection as part of workflow. We are also thinking about longstay patients, and if you
could halve the amount that people were spending in hospital, you would release about 30% of the
current bed stock. This would move us from having a bed problem and a flow problem to organising
So, as we move to solutions, think how to speed up the journey. Think of what is required. One size
will not fit all for people, so it needs a differentiated and thoughtfully put together approach.
So, in conclusion, the environment is changing rapidly, and we all know that we can't tackle it the way
we are at the moment, and that we need to find different ways of managing flow, thinking through the
needs of different segments of patients in the system.
I will leave you with this picture. That's what comes out of that jigsaw that I started. I think it is time to
remove the blockages, and for those of you who are interested in the theory of constraints, that is
I will leave some time for discussion, and I hope that has been helpful to you.
Janet, do you want to… Come in and see if there are any questions?
Thank you. That was fascinating. There has been a lot of activity in the chat room. I wondered if I can
go over to Don to get a summary of the things that have come up there and on Twitter.
Apologies. It looks like we're having some interesting conversations. One of the questions that has
come up is what is driving the zero day patient trend? There is a separate conversation around real-
I think what is driving the trend is multifactorial. It is not completely clear. I think it is coming from two
directions – one is were getting better at solving problems faster, so some of the growth is by stopping
the need for one or two day stay in hospital because we are much slicker at it. Some of the need is this
increase in complexity, and in GPs on doing a fantastic job of intuitively managing people with
increasingly complex needs, but the size of the population with three, four, five long-term conditions is
growing enormously, and you get to a point where you need access to specialist diagnostics, and you
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need that in a coordinated way, which at this point in time is difficult to do outside a hospital setting. So
I would say those are the two key nonelected pressures. On the elective side, again, more and more
day surgery is happening, so all of those things are good, but it requires a different standard of flow
management, and the move towards real-time data to do it slickly, I think.
In terms of data collection, I think it is really, really important. A few years ago I met a chap who was
the research director at Microsoft, and he was actually a doctor by training. We asked him, "Have you
any tools to manage flow-through hospitals?" He said he would love to solve the problem. It was so
difficult. It was easier to map traffic flows around Seattle. At least the staff could get home in time and
think about it. Over the last about five years I've heard that story. Over those five years, the ability to
get data really cheaply has changed exponentially, so very few hospitals now don't have Wi-Fi. We
have a whole raft of tracking devices, we have new sets of tools around visualising data, and I think
there is a role for many of these, but it is really, really important to think about the workflow and
experience we have designed both for the patients and for the staff. If we simply add this into a chaotic
system without thinking about how to simplify, I think will end up in a bad place.
Just to illustrate that, asked the designer to have a look at some of the patient flows for complex
patients and one of the hospitals I worked in. He said, do you know how questions are asking
patients? The answer is 1400. Some were duplicates. We had invented 28 different forms for the staff
to fill in. You can't think that process will be very quick and all of those questions will be that relevant to
the safe delivery or the efficient delivery of care, so I think we need real-time data, but we really need
to think through how to present that to people in a way that is useful to them.
Interesting. "Is a motorway more like the flow of under 65 patients rather than the patient's use in
SPEAKER: It is a very good question. I think the interesting thing about traffic is it represents
everybody, and I think the flow through a general hospital represents everybody, so you will get some
people on a motorway travelling one junction, you will get some people who you would not want to be
driving next to, because they aren't quite as aware and responsive as others. The same applies to
hospitals. We have a pastoral people moving very quickly, but we have some slow ones. I think it is a
reasonable and allergy. I think the important point, though, it is not just about the people using the
service, it is about the interaction between them, so if you think about your own car, it is perfectly
capable of travelling at least the speed limit, but if you're stuck in congestion, you will not be able to
use that potential, so actually it is the interaction between patients that matters as much as the specific
types of patients in a flow situation.
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Thank you, Sasha. One comment – Melly says if staff and patients think beds would be a solution, but
we can do for them, it would be a massive barrier. But it is more about safety. We must value our
patients' time and we need to deliver this message in a strong way, and we cannot afford beds.
I think that is a really good point. I know that if I suffer a poor experience, it makes feel angry and
unhappy in a hospital situation. I think that notion of valuing firstly the patients' time, but also valuing
colleagues 'time might well help us handle the resource constraint.
That is really helpful. We are slightly early, but I found that hesitation fascinating. What do you project
for the next couple of years going forward in terms of flow? Do you think we have the right technology,
right know-how, right approach to how we manage data to move this to another place so we will not be
having the same conversations in a couple more years?
That is a challenging question. I think we really difficult. The challenges are real. We will have to run
faster to stand still. That said, there are significant numbers of really innovative players in the tech
sector who have interesting ideas and approaches that could make a big difference. I'm aware of really
interesting innovation in out-of-hospital care that is starting to make a big difference. Those sorts of
innovations, the harder we do rehabilitation, how do we systematically enable people to connect to
voluntary help in their communities and so on? I think, for those who are entrepreneurial, those who
really want to make a difference, the next two years could be really exciting. The biggest danger is
saying it cannot be done, or trying to be too cautious. I think we need big energy, and to use the best
skills that exist within the health service, also the best skills that exist without it.
In terms of having three main points you would make to NHS England and maybe MPs today, what
with the three main points be following some key issues you mentioned?
In terms of your last point, I think we have to aim of the problem as a system. We have to be precise
about the request to MPs and people outside the system. This is largely a technical problem, but we
have to have a very clear ask, how would we like customers to respond? What help do we need from
wider society? I don't think we should ask a panic to a general question.
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My key message regarding problems is this is not a time for people to be acting in a hierarchical
judgement away, it is time to be acting to be bringing the knowledge they have to the table and to
make sure we use all of the parts of the jigsaw, not just a few of them, because it is a very complex
situation, it is a fast moving situation, and that implies the need for very active teamwork, so my
metaphor for that is the Apollo 13 film, for people who have seen it. We need that kind of urgency and
collaboration to really drive innovation.
I wanted to go back to your role within Horizons. How do you think the team and what we do could not
necessarily resolve the issues, but bring it up to the priority list for NHS England to address?
in a number of ways. One of the really interesting things is there are lot of people close to the front
line, involved in the school for healthcare radicals who have fantastic ideas, and we can help, I think, in
convening those ideas and helping people to test them and put them into action as quickly as possible.
The other thing we can do is to share our knowledge of innovation happening in the world. Early in the
week I was talking to some European colleagues. They were judging a connective health award. We
had ideas from all of these sorts of themes I talked about earlier on today, so we don't just have to look
within the country, there are some interesting ideas emerging right across Europe and around the
world, so I think we can share some of those ideas and hopefully get them into action faster.
Fantastic. That is it for now. Do you have any last minute thoughts you need to share? I think you've
taken us through quite a journey today, and a lot for us to think and reflect icon. We have a couple
more minutes. Is there anything to end with?
I don't think so. I hope that has been really useful. I am happy to respond to questions or thoughts that
people have after the event, and if there is anything we can do to help, we are open to having a
conversation about that, so I hope that has been useful, and it has been a pleasure to put together.
I think everyone in the chat room would like to say thank you. It has been helpful, useful and lots of
positive comments coming through. We appreciate you sharing all of your expertise with us today. We
are going to be talking about the next Edge Talk coming up shortly. Empowering people to be heard
and helping leaders to listen. We look forward to seeing this and hearing about this fascinating subject.
We afford you coming on the next Edge talk session. We hope you have a fantastic weekend. Thank
you for contributing and supporting the session today. Thank you to everybody. Goodbye and have a
good weekend. Bye.
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