Tara Klassen, PhD: Hi, Tracee. Thank you so much for taking the time today to talk to you about the program you have at the Lois Hole Hospital in Edmonton, and the work you've been doing with your robotic assisted surgery system. I see that this is a 10 year anniversary, 2025 for your program at site, and you've done over 3000 procedures in that 10 year time span. And last year you were the single busiest robot in Canada with 425 surgeries. I'm really curious to, get your take on your program and how you've seen it evolve over the last decade.

Tracee Pratt, Executive Director: Thanks so much for having me, Tara. It's always great to be here and to boast about the program that the team has done such an incredible job over the last 10 years. So I'm really happy to be talking about the program and what our future state looks like as well.

Tara Klassen, PhD: Okay. So when you think about your program, I'm really curious, it's seen such great successes. Would you consider robotic assisted surgery to be a standard of care for your patients at your site?

Tracee Pratt, Executive Director: Certainly in the gyne oncology world, I think our providers, practitioners are some of the best in the world. They really establish themself as the key site for robotic assisted surgery in the women's health area.

Tara Klassen, PhD: When you think about your program and the procedures that you do, you mentioned, oncologic gynecology. What are the kind of bread and butter procedures that your team sees on the daily?

Tracee Pratt, Executive Director: For sure robotic assisted hysterectomy. So whenever there's an ovarian or endometrial mass, even cervical masses, the surgeons were going in and we started small. How do we do this? How do we expand? But even with those procedures instead of doing an open procedure, using the robot has really reduced the patient impact, honestly, of these procedures.

So when they're doing the procedures, they actually found that the cervical procedures weren't as effective. So they really started to focus in on the endometrial cancers. Ovarian cancers. And what this means for the patients is their length of stay, that used to be a three four day length of stay in hospital, away from family support, has now been reduced to 24 hours. So they're going home next day or same day. And if you can imagine the impact that has on a family that's away from their loved ones, just being able to go home and recover in the comfort of your own home without a major abdominal open wound. Significant, significant progress. So I'm really proud of our team.

Tara Klassen, PhD: So, Tracee, you said something that's really interesting to me, which is the patients get to go home, they're not away for a long period of time. I know Edmonton is a Center of Excellence and a center of care for gynecological oncology. What is your actual catchment region for those patients? How far do patients actually travel to come see you?

Tracee Pratt, Executive Director: Certainly we are the Western Canada. We would see many patients from up north or northwest territories and none of it, we have reciprocal agreements in place, so those patients would not follow the natural referral pathway down into Edmonton Zone. Obviously the North Zone, which is a huge diverse and dispersed geographical area, so anyone north of Red Deer, all of north of Alberta, and of course the Edmonton Zone, but yeah, into some areas of BC, Saskatchewan, and then definitely Northwest Territories, none of it.

Tara Klassen, PhD: So you said something that's very important in my mind is that it's sort of red Deer North that is your world. What does that actually look like for patient and pathway of care? Because Calgary, surgery, surgical oncology lacks a robot at this point. So how does that intersect with your world, or how does that influence the patient care journey?

Tracee Pratt, Executive Director: Well, certainly we're not saying that Calgary doesn't have an excellent service as well. The Lois Hole is fortunate in being the only one of three or four women's hospital in Canada actually. So we take that and we're very proud of that fact. So what our patients can expect when they come to our surgical service area is that they're going to have their consultation with our GYNE oncology for their ovarian cancer.

Our robot assisted surgeries are focused primarily on only cancer. We don't use the robot for other surgeries like urogyne, or general gynecology at this point. I think there's a future state for that. But currently for cancer care in Alberta, that's our focus in GYNE oncology. So they can expect to see the surgeon.

The surgeons are amazing at what they do. They pool their resources. So you may see one surgeon, but you'll see one of seven or eight excellent surgeons, whoever's there available to get them in as quickly as possible to meet our wait time targets. We started off very slow as a program to do one and the training for the physicians and the entire surgical team is so incredibly important so that team can function as efficiently and effectively.

And we didn't start off by being able to do four complete cases. When we first started, we started off with one and two, and as our expertise has grown, we've now gone up to four cases plus the efficiencies of our surgical team is just incredible to see. And that results in better outcomes for patients, shorter length of stays, less complications, less surgical site infections, getting home and getting back to their lives.

Cancer is incredibly disruptive to your life when you get that diagnosis. And so if we can get those patients safely back to their lives, their surgical care is completed, we've taken out that tumor mass and that's for staging and whatever is next on that cancer journey, whether it's chemo, radiation, or the surgery was enough, that's our aim.

And to provide those outcomes to patients. I don't think we could have asked for better results at this point.

Tara Klassen, PhD: And Tracee, I do want to actually unpack that a bit further with you because I do know that philanthropy helped you get the first robot in 2015, but I believe your foundation also supported you in gaining the fluorescence in 2019. Can you talk to us about what lighting up the cancer actually, that campaign looked like?

Tracee Pratt, Executive Director: Absolutely. So from the Royal Alexander Hospital Foundation, they were our key foundation program that helped raise the money So the $2 million ask. Once we raised that, the Lois Hole Women's Society, which is a subset of our Royal Alex Hospital Foundation, a very interested women and partners dedicated to focus research in women's health said, what can we do next? What, how can we help patients even further? The next evolution of that was to get the Firefly so we could fluoresce those sentinel lymph nodes, the ones closest to the original tumor, kind of the, the guardians of the galaxy, I guess. If that's a good analogy.

 So how can we identify those nodes that are closest that would tell us whether or not the cancer has spread into the lymph nodes or not. So we can preserve that lymphatic system, which is really important for ongoing patient health and better outcomes for patients. So yeah, so that was a $300,000 fundraising.

 They did it in a very short time and actually the Lois Hole Women's Society has raised of $1 million now to help us support other initiatives, but certainly the robotic fundraising was so incredibly exciting for our patients, exciting for our donor partners. We actually had an event when we reached the mark to bring everybody in and they got to play with the robot. We put the donor's hands in the robot so they could see what that looks like. And that just further excited our donors to support this incredible initiative. So we can't do this without our partners, our donor partners, and of course our physician team is always willing to help us out and understand what's next in care, how do we get the teaching console is our next evolution, so we can support more learners across Canada.

Tara Klassen, PhD: Fantastic. I love the fact that your foundation is so proactive and involved in your program. Now you said something really interesting to me, which was putting the hands on the robot. Now, most of the time we don't let people play with our toys. And so I do want to take a, take a moment to talk a little bit about that whole surgeon experience behind the console and what that's actually meant to you in order to achieve the efficiencies that you see in your program.

Tracee Pratt, Executive Director: Absolutely. Yeah, it was quite unusual to have an open house into our ORs, but we wanted to see the impact our donors are having on patients and outcomes, and so being able to see, well this is what you're referring to. Because often we talk in our medical nomenclature constantly, and we forget that the layman doesn't actually know what we're really talking about.

So how to not dumb it down, but just explain it in a way that they understand. So when we are able to get their hands on the technology, they can see, oh, okay, this is what that means. And then from our surgical point of view, for our surgeons to be able to plug and play and get in there and play with the instruments.

That's why that teaching console is so important for the next generation of learners. I know we have a generation of physicians that don't do minimally invasive surgical techniques and the robotic techniques, but the new generations, that's what they're going to do.

That's the future of medicine. And so how do we get that in their hands so they're comfortable? And the more practice, the better they get, the better they get, the better the outcomes for the patients.

Tara Klassen, PhD: So you've talked a bit about the patient experience and journey. We've heard in the literature and from your surgeons themselves that their clinical outcomes are better. And it always comes with a bit of a jazz hands around what that means. Are you able to speak to any of those pieces around, do you see your patients back again or is the cancer gone or what, do we see, I need to move from a robotic to a, an open incision? Are there any complications or concerns or successes that we should be aware of?

Tracee Pratt, Executive Director: For sure when you have any surgical activity, there is complications that can occur. I'm pleased to say that the robotic complications are lower than regular complications, ie from an open case when you're doing an open incision and right into the cavity like that. From the robotic assisted surgical interventions, we are seeing almost a complete dissection of tumors and the associated lymph nodes due to the Firefly and the fluorescence of those. I know that we're doing more studies. So relative, this technology in Alberta and at the Lois Hole is still relatively new. So going on 10 to 15 years now, we still need to see more research in what those outcomes are doing, but our teams are engaged and our patients are engaged to say we want to make a difference for women that are going through the same journey as us. So maybe one day they won't have to go through this. So still early in the literature, I know we've done some preliminary research, that's showing evidence that certainly the length of stay has reduced.

Certainly our surgical readmissions and infections rates are lower in this population, but we can still do more. So looking at those quality improvement opportunities and research opportunity, women's health research, if I may plug, that still needs to have more, more, more, more women's health research because often the research and the medical treatments right now are based on the research we do in men's health and women are different.

Tara Klassen, PhD: Fantastic. I really appreciate that distinction. And I know that the urology space has long been the source of much of our research. So being able to transition into a women's centered focus and have the Lois Hole hospital as a dedicated site has been very powerful and we look forward to continuing that journey.

Now I want to move a little bit away from the patient experience because obviously we're seeing a great opportunity there. The clinicians are seeing great clinical outcomes, you're seeing lower rates of complications, so it's hitting all of those sort of traditional metrics. Now I want to talk about what the robotic assisted surgery has meant to you as an operations leader because I'm going to let the cat out of the bag here. You have actually eliminated your wait time for your surgeries in your program. I really want to take a moment to hear how you've achieved that and what that means to you.

Tracee Pratt, Executive Director: Thanks for calling that out. Our entire surgical team is very proud of this fact. The caveat being is when you do so well in eliminating a wait list, what that brings is interest to see how you did it, and then do you need all the resources? So if we go back to how we did it, when we started with the robot, our surgical team was given three days a week in booking, and we recognized that we weren't making a dent in our surgical wait list.

We were just maintaining, and we wanted to get these women in as fast, so the tumor doesn't have any chance of growth. And going to the next stage, which is the most alarming thing for women and our providers. So we were able to increase with our collaboration between anesthesia and our surgical team, and invest in more time for our GYNE oncologists to have days.

So we increased to five days a week. So we almost doubled that activity. And then with their skill, the surgical skill of the surgical team and the provider in there, they're able to go from two cases to three cases, and now we're up to four cases in some cases, which is a great. We also increased our anesthetic resources.

So instead of just doing two cases a day, because those surgeries take a long time, having our anesthetist support until 5:00 PM every day allowed us to get that third and fourth case in. So we were able to very deliberately plan three to four cases per day, which started to really eat away.

And it wasn't that we were, we were intentional. We wanted to reduce the wait list. We just didn't know how effective we actually would be in doing that. And there are certain, a subset of GYNE oncology cancers that still have to have a minimally invasive approach or a non robotic approach or an open approach.

So we do make time within that period within our case to say we need to switch to an open or we need to plan for an open for various reasons. But having that dedicated five days a week additional time. Most surgical days end at 3:00 - 3:30, we're able to go to five. That allowed us to get another case in, all of which optimized the surgical team time and then the patient experience, obviously, and being able to reduce them, not plugging up our beds for the surgical inpatient stay because they're now going home within 24 hours, that allowed us to have some really magical flow in the inpatient world. So from an operational leader from a cancer survivor, myself, I'm so pleased that we're able to help women, to do this because living with that anxiety of cancer and knowing, okay, hurry up and wait, hurry up and wait.

When's my surgery? When's, when is it? and we can give those answers now. We can say we are maintaining our wait list. So if you're booked, you have a GYNE oncology cancer, within two weeks, you need to get in. We can get you in, in two weeks. So this is your plan.

Tara Klassen, PhD: That is just absolutely amazing and congratulations to you and your team for achieving such an amazing feat, especially in a resource constrained environment. You said something important there, which was really the buy-in from the team and the team members include your anesthesiologists, and I do want to sort of look at that because we keep hearing in the news that there's an anesthesia shortage.

So have you had any experiences or impacts on your program in relation to your anesthesia resources?

Tracee Pratt, Executive Director: Absolutely. We have full functioning ORs that we're not able to operate in Alberta because we have such a shortage of anesthetists. So the surgical teams across the site, across the zone and across the province are all looking to see how do we support anesthesiology care in Alberta.

What does an anesthetic care team look like? Looking at different models of care to try and get all ORs up and running as efficiently and effectively. That's no different in the women's OR sphere as well. We have days where we can't open a theater because we don't have an anesthetist present.

Tara Klassen, PhD: So keeping with the theme of chaos moments, and you mentioned the impact on inpatient stays and the ability of patients to go home in 24 hours, are there any key learnings whether that's from your, you're staying late till five o'clock or needing to move people into patient or book different cases to make that workflow work.

What do you see in the Lois Hole in terms of needing to achieve that efficiency or avoid the bottlenecks that chaos brings?

Tracee Pratt, Executive Director: Oh goodness. And I, a huge shout out to our booking teams and our surgical teams that handle the booking process. Because it is a quite a convoluted process for sure. So making sure we have our minimum surgical time maxed out with our maximum surgical time looking at the case mix, groups of patients.

You can't do four huge cases every day each and every day. It'll plug your system up. So doing a couple smaller cases with a couple large cases. So really that predictability of case time and managing that in the OR sphere. So knowing what the day surgery appointment looks like, if they need a pre-admission appointment with an internal medicine or an anesthesiologist of course to help that patient flow so the patient is aware of what they're time when they show up, minimize their wait and get into the OR, have their surgical period. Have the post anesthetic care and then out to the inpatient unit and know what to expect. The biggest part for patients is understanding that no, you will go home within 24 hours.

I want you to expect that. I want you to plan for it. You will be safe, you'll be stable, you'll be in a very good space. We're not going to send you home if you're sicker than we expected. But having that patient expectation to say, Hey, I actually can go home. No longer are we staying in five days for. Remember when we used to stay five days for having a baby? Well, that's no longer a thing either. So in the GYNE oncology, it's no different. Let's set our patients up for success by helping them know what the expectation is. How do we mobilize them early in the prehab care, that's a thing. We also are really proud of a small program that we have for patients who need some rapid weight loss before GYNE oncology surgery.

So a rapid weight loss of eight to 12 weeks prior to surgery. If you're a bit heavier, and able to shed some of those pounds, you're going to have a better surgical outcome and post recovery. So we want to get you moving, get you active, adjust your diet as much as we can.

So then you too are going to have a positive surgical outcome, all which speaks to your total health, when you need to go into further treatments for your cancer care.

Tara Klassen, PhD: You mentioned something there that actually made me think about one of the things I heard from a surgeon about the patient appropriateness for going into robotic, laparoscopic surgery and the fact that it's actually more amenable or we can do bigger bodies than we would normally handle using traditional stick, laparoscopic surgery.

So, really, is it true that we might be transitioning from patients who would go open under other modalities, now can be done through this minimally invasive approach?

Tracee Pratt, Executive Director: Certainly some of our bariatric patients are perfectly appropriate to do the rapid weight loss program. Just helps that gives them an extra bit of a oopmph to say, if we can reduce some of your preoperative weight, you're going to have a better outcome in recovery, less chance of pneumonias, less chance of throwing any clots. Mobilization is going to be easier because it still is a major surgery. But if we can do it minimally invasive, we know your outcomes are going to be better overall. So yeah, we want to help and support you along that journey to get there. And then you can make the decisions on what that sustainability looks like as a patient.

But yeah, I think, we are growing to understand, our physical bodies are growing across the world. We know that. So now we have to adapt our surgical tables. Our instruments are longer. Our surgical tables hold more weight. So I think it's the next evolution as well.

Tara Klassen, PhD: Wonderful. So I'm going to go back up a bit now and you talked about complexity and, booking and doing like, sort of two minimal cases versus some complex cases. But then you said your evolution was like one to two, to three to four. Is it actually, do you do four surgeries traditionally, minimally invasive in an afternoon, or is that, is that physically possible for a surgeon?

I just think of standing at a table versus sitting at the console. Does that make a difference?

Tracee Pratt, Executive Director: Yeah, I think that's a provider. Certainly I'm not doing the surgery, so I can't speak specifically to that, but certainly our providers are able. Some of our providers can do more than the four cases a day as well. But on average we're able to do three to four cases, no problem. We have a minimally invasive suite where we're booking up to eight cases.

It really depends on the complexity of the patients, the comorbidities, and other things that are going on to see how many cases. Certainly open cases take a bit longer as you go through the closures of the skin and the cavity, the skin and everything like that. But this is the evolution going forward. Minimally invasive robotic assisted surgery, this is the future.

Tara Klassen, PhD: Now I want to get into the, the nitty gritty a little bit, which is the financials of robotic assisted surgery because we know that everything that wants into the OR tends to cost more. That's pretty much a truism, but I'm hearing that there's some fantastic outcomes and things that are helping there. What has been your experience with your program, and what have you had to invest in order to keep the train on the tracks?

Tracee Pratt, Executive Director: If we consider the consumables for robotics and not the cost of the equipment itself is a fair chunk, it costs more to do a robot surgery for consumables, the things we use for every patient case, than compared to an open case. But when you consider the system costs, ie the length of time, the cost to the patients when they have to stay two or three days at a bedded cost of $4,000 per day; if we're getting our patients home, we're reinvesting that money into the consumables for robotic assisted surgery, and you overall have a net win. You have net gain rather than a net loss of OR costs, which is fantastic.

But that does require dedication and investment into the team training. The vendors have been fantastic with their training for us, taking us to where their locations are so they can explore. And now we're paying it back by being one of the foremost, accredited institutions in Canada that has fellows coming from across Canada to train with our GYNE oncology surgeons, and surgical team to say, they're sending their fellows to us, which is fantastic because we're getting the next generation of specialists into our program. So, we pay it forward. But we really appreciate the time people have taken to train our team in the surgical skills.

Tara Klassen, PhD: Your program just underwent an evolution in the robot so over the decade you started with the, the Da Vinci SI, I believe, correct?

Tracee Pratt, Executive Director: I think so. Yes.

Tara Klassen, PhD: So now you have a new robot. So what has been that experience been like, and, what can you speak to about that robot as other programs look to bring it into their, their program?

Tracee Pratt, Executive Director: Certainly, with any change comes a change process and how to change management for our teams. I can say that the vendor was highly responsive in coming to our surgical teams to help them understand they were onsite during the transition of change. A couple of hiccups along the way, making sure we had all the right equipment because our medical device reprocessing process changed with new technology.

So making sure we had all of those pieces and, you were one of the people that absolutely helped us get on track and to make it as less bumpy in the entire review of things. So yeah, it, it's a change for the team, but what they found is that there's more technology.

The teaching console has been fantastic, which is great. So hopefully we get more robots. Now the competition, not competition, now the challenge is everyone wants to be part of robotics. Yeah. And we'll get to that probably in another question.

Tara Klassen, PhD: I want you to talk about your vision. Now, obviously at 425 surgeries a year, at four surgeries a day, there's no more room on your robot, to achieve more efficiencies. You can't do more than what you've got. So I'm assuming that means more robots into your program. So what does that look like to you and what do you want to do with those robots going forward?

Tracee Pratt, Executive Director: Certainly we've all, anyone that's got a robot in their ORs is looking at your OR utilization. So we are at a 97% utilization with our robots, which is fantastic because you don't want it sitting not used. That's not good for anyone. Certainly all programs on site are wanting robotic time and robotic use.

So in the women's program, we see huge benefits in the general gynecology world. We also see the urogynecology world stepping into this field. Right now across Alberta, the focus for robot has been on cancer activity. If we can open that up to see non-cancer benign activity, we're certainly going to see a reduction in system costs because we're going to be able to reduce the length of stay in patients and we know the capacity challenges across the province.

Our emerge wait times, our EMS off load times. Certainly our surgical flow through is great, but we, I think we can make it better. I think that's the future of the robots. If I had a magic wand, I would say the next evolution is to say, okay, do all services that have cancer patients, thoracics? Are they using the robot?

And how do we help support that growth of those other programs and services? Yes, I'm advocating for women's health. That's my program, but anyone that has cancer should have an opportunity to have access to a robot. Your outcomes will improve. Your life will improve. So how do we make that happen?

And that happens with more robots, more investment by our governments, by our donors into robots for the entire site. So every OR has opportunity, multiple opportunities to use robots for all programs and services.

Tara Klassen, PhD: I appreciate your pitching for colleagues and what I'm hearing is it's great for cancer, for all of the reasons in terms of outcomes, length of stay, the clinical provision of care, and not having the readmissions, getting great margins, using a fluorescence to check nodes.

Because I have to assume that that's not just for the gyne cancers. But I really appreciate what you're saying about the benign world as well and the and the procedures there. Because really what I'm hearing is it's not about the cancer, it's about the robotic assisted approach and the precision that it brings to execute the plan that the surgeon has, and not be hung up on patient anatomy or, size of body or ability to stand at a table for a particular period of time.

And so you have to default to a different option. I think that that's really impactful and can be impactful for benign as well.

Tracee Pratt, Executive Director: Thanks, Tara. You said it very well. Yes, for all cancers. We want everyone to have an opportunity to have a robotic assisted surgery where it's appropriate. Not everyone is appropriate. But as we move into the benign world, other jurisdictions are having tremendous success. And that's the nature and evolution of medicine as well.

So where can we go next? We've got these very expensive machines. How do we use them to their fullest ability, to the fullest capability of our providers? How do we train more? How do we get, and I think we're just going to get better and better at that. But yeah, the next step is once everyone in cancer's got access to it and has a perhaps a paper use or whatever that looks like in our models, but then how do we bring in the benign worlds as well to give every patient that opportunity for a reduced length of stay, less trauma to their tissues, less open wounds to heal, because that will reduce all complications.

Tara Klassen, PhD: Now I want to switch over to one of the questions that I have from a leadership lens, which is you keep talking about the training consult, you keep talking about the trainees. You're talking about fellows coming from across Canada to join you and train at your program because of the outstanding nature of it.

I'm curious, does robotics play a role in the recruitment and retention of, of trainees either to the MATCH program for residencies and fellows, or even into the hiring for new surgeons at site? Have you seen the robotics be a bit of a carrot there for bringing new people in?

Tracee Pratt, Executive Director: Absolutely. And as we're a Center of Excellence, we want to attract the best of the best across the world and what does that look like? And having the leading edge technology is certainly an attraction because new generations are learning these techniques in residency. So how do we lead this work, the innovation of the work? People are drawn to that. And so we are, one of the drawers that bring our GYNE oncology program is expanding. We have more surgeons that are doing fellowship trained in minimally invasive and robotic assisted surgery. So having that, that's an, that's almost becoming a standard of care.

It's not even a Center of Excellence. It's a standard of care. So what, how do we go to the next level? What does that look like?

Tara Klassen, PhD: Now I'm going to just kind of give you a bit of an open mic here. Like if you had a bit of a, either a, a, a sales pitch or a checklist to support your, your colleagues across, uh, Canada and other centers in understanding the impacts and what's needed to be a successful robotic assisted surgery program. What does that look like to you? What are the things that are must haves and what are some of those little unknown nuggets of wisdom that you've gleaned from a decade's worth of experience?

Tracee Pratt, Executive Director: Thanks for this opportunity, Tara. I think having that leadership buy-in, I think is key and, and important because we know that our senior executives hold the budget. But we need advocacy. We need a robot in every surgical suite across the province, not just in Edmonton. We need all patients, not just women's health patients, but all patients have access.

It involves the providers having that passion and interest and engagement to say, how can we be supported when they come with new technology? And often it is our new providers that, our providers that are coming to us with great ideas, how can we support that? We need our foundations to continue to invest in these programs that will draw the surgical excellence from across the world to sites like ours at the Lois Hole at the Royal Alexandra Hospital. We need the surgical team to buy into that. So dedicated training time to help them be comfortable so they can be as efficient and effective as possible. And all of that will contribute to a safe team, which will give the best quality care and safe outcomes for patients.

So it's not just one layer of the organization, it's every layer. It's every family out there that's had a patient who's had a successful surgical outcome, gotten rid of their cancer, invest in our foundations. It's the foundations going out to spread the good news. It's people like me coming on talk shows and people like you helping us come or podcasts and helping us have a platform to say, we can make a difference here.

We can change the lives of Albertans, of people across this country of Canadians. We can make a difference, but we need to invest in our surgical robotic assisted surgery techniques to be able to do that. We need more robots. We worry about AI coming into our every facet. This is no difference. AI is showing us what we can do, and it's now time to open ourselves up to learn what that is.

What an opportunity, We're so blessed to be part of this generation.

Tara Klassen, PhD: Wonderful. And I like what you said there around the idea that innovation continues to evolve and we're seeing new generations of tools, new generations of robotic assist. You've done the, the upgrade from the SI to the XI. We see the Da Vinci 5 in the US just received their licensure. So we fully expect that there's going to be a new surgeon who trains on that, who then we want to recruit up into Canada.

So I can appreciate that from all of the lens. I'm going to distill it down now. I'm going to, I'm going to take a bit of a step back and say, when you think about your successes and you think about that daily workaday world, do you have a specialized robotics team? Like is, the literature's filled with this sort of pit stop model of everybody has a role and everybody has a path. Is that what your team looks like daily?

Tracee Pratt, Executive Director: Yeah, we have dedicated, not all OR staff are trained in the robot because we want to make sure that we have the volume of surgical activity and time to learn that effective, efficient process in ORs. So we have dedicated staff, peri anesthesia trained nurses that know how to use the robot, how to support the provider in using that robot.

Of course, it's our gyne oncology team that is only using the robot and they've stated on several times how much better it is to have the dedicated team that they can work with. You learn to anticipate during an OR and that's the biggest skill we can give our providers is having those nurses be able to anticipate what's coming next.

If a bleed occurs, how do we put that out really quickly? How do we cauterize? And that anticipation of the surgical team has really been part of our surgical success from the providers, from the anesthetic team, but also from the frontline RNs and the LPNs that are doing that day to day surgery. Day in, day out.

Tara Klassen, PhD: So experience really does matter here. It's not just about the surgeon's hands, it's about everybody on the team and in the pathway.

Okay, wonderful. Now I'm going to put you on the spot because obviously Alberta's in a great state of healthcare reorganization and, we're seeing that this is a, a significant change in how things are happening.

Recently we heard the announcement of the potential activity based funding or the patient focused funding. This is the same funding path that Ontario and Quebec use for their robotic assisted surgeries. I guess that's a two part question, is one, do we have any special billing codes or, or extra funding that supports your program in doing robotic surgery? Or is it all the same budget right now? And do you think that might change come future state?

Tracee Pratt, Executive Director: Yeah. Alberta is in a bit of a state of reform or restructuring for sure. It's an interesting time in healthcare. What I have to believe in activity-based budgeting doesn't scare us. We've been in some form or another in Alberta for a very long time, so that's not new concept to us.

What it does allow us is to standardize some of the costs per case. So where you have one provider that has a preference over another provider's preference, one may cost more than others. So it's up to us and we owe it to all Albertans and all taxpayers to be as judicious as we possibly can in costs to Albertans.

That includes how do we standardize costs and decrease costs where we can. So yeah, I'm looking forward to activity based budgeting and, and following some. There's going to be some bumps for sure as we learn and understand the methodologies. But I do believe that we're going to come out ahead for Albertans.

And it's up to me as one of the operational leaders responsible for the fiscal accountability to all taxpayers to make sure that my team is as efficient as possible, that we're using our resources in a very judicious way, that we're not wasting resources, but we're maximizing and optimizing resources. So I'm all in on the activity based budgeting.

Tara Klassen, PhD: That's actually a really positive lens to have, because we do see success where it allows us to not focus so much on the procedure, meaning like a malignant hysterectomy, but also incorporates the modality or method, by which you're going to go after that particular target. So if you're using a robot and those instruments cost more, it gives you an opportunity to, invest there. Whereas if you're doing an open surgery, you might spend less on the, the particular OR instruments, but then you're going to see that in your aftercare. So it gives a bit of a chance to balance out some of those successes with some of that costing directly.

So I think that's a positive opportunity that is timely given the interest of robotics in the province. Now, when you think about your program and you think about what types of environments that robots are most successful in, we often think about them as being affiliated with our academic, research and training institutions. Do you see a role for robotics in other locations across the province?

Tracee Pratt, Executive Director: Yeah, certainly the Lois Hole is affiliated with, we have our faculty of OB GYN, right on site here at the Lois Hole and the Royal Alex campus. Certainly that helps with the learner portion for residents and medical students to become familiar with operating with robotics. I certainly do see a role in the non- academic affiliated centers across Alberta as well. Because it's the patient outcome that's the best here. We need you to have the volume to be competent and capable in the robotic assisted surgery. So you need to do enough volume. So we may not be able to put it in every center, in every OR in Alberta, but where you have that volume to sustain your medical training, to become as efficient and effective because it is more costly.

 What does that look like for those centers? So certainly our level twos potentially, certainly our level threes. But looking at those different layers and how do we support it? So I do see there's growth absolutely. Plus our residents and our medical students are going all across Alberta as it is so, and nursing students as well.

So we want to support that ACE to the recruitment at that site as well. And we often find it really difficult to recruit into our rural sites or more northern sites or our more southern sites. So how, if we have a robot, it can attract our providers to that community and what a huge gain to that community to have that surgical lens there.

Tara Klassen, PhD: So what I'm hearing is it's not so much a site is too small, which is the normal optics that we have around rural or remote hospitals, but it's actually around the team that's there and the number of or volume of a particular type of procedure. So, it might not play in the cancer world as much because those tend to be localized to the pathways of care and the integrated care networks around those centers.

But as we see benign growing and I'm thinking about the hernias of the world, there's probably just a magic number where we're like, beyond so many cases, it would make sense. Below so many cases, it's probably not doable from the skillset, let alone the, the fiscal side of owning or maintaining a robot.

Tracee Pratt, Executive Director: Absolutely. And don't forget the draw of patients to come to a site. So they might be coming from outside the community. So you can still obtain volume from other methods to draw as a referral center for non-malignant cancers per se. So I mean, that's a, it's great for the community to have others come in and making sure our referral pathways are strong and they have those supports needed when they're discharged.

But certainly we know in other centers we bring in activity from other areas in the catchments to help support surgical volume. So you gain and maintain that surgical expertise.

Tara Klassen, PhD: You've answered most of my questions. I'm certain that afterwards I'm going to think about all the things I didn't ask you, but I do want to offer you the opportunity to pitch, plug or put in the cell for, for yourself and also for like-minded programs across the country that are still facing the, the need for onboarding leadership and that sort of executive level buy-in around the investment.

It comes with a big price tag. So what do we get out of it from your operational lens, and why do you want more robots for yourself and your colleagues?

Tracee Pratt, Executive Director: Oh, thanks Tara, and thanks for this opportunity today. It's been a, a great experience. Ultimately, the patient is the center of our care, so what we get out of it is we get better patient outcomes. When our patients are happy, we are all happier. When we have patients happy and going home within 24 hours, we have less burdens on the healthcare systems overall.

So the plug, if you're not having a robot currently or not, not sure where to start, reach out to somebody that's got a robot. Yourself and myself, we've all got plans and programs that we can leverage to help support the cause. Get out to your foundation and start to socialize this idea to the community members that support the foundations.

That's probably going to be your biggest bang for your buck is awareness. Reach out to those centers that do have the robots, not just in Alberta, but there's centers across the world that have this. That's where we started. We didn't start out with all the answers and we've learned a lot, but we still leverage from other jurisdictions as well.

Look at the research. Women need more research. That's my plug there. So be part of this study and yeah, just embrace technology, embrace the innovations that come with that. It's an exciting time.

Tara Klassen, PhD: One last one. You're 10 years into robots. Where do you see robots 10 years from now?

Tracee Pratt, Executive Director: Oh my gosh. I think we're going to get to where lasers, just like Star Trek did, you know, remember the old cell phones and the transformers? I think we're not even going to have to cut in, in 10. Well, maybe that's 20 years out, but I see a robot in every OR. And certainly every large site that can maintain volumes.

I see the need for open cases, really lowering. I see the technology growing, so we're doing it faster. We're doing it smoother, we're doing less complications. And maybe we can eradicate some of these cancers out there as well. The benign world certainly needs to come into this world as well. But right now, the malignant world, there's too much cancer in this world and we need to eradicate each and every cancer.

Tara Klassen, PhD: Thank you so much for taking the time to talk us through your experience. I'm excited to continue to be on this journey with you and your site, and your program. I am one of your biggest cheerleaders, your strongest supporters, and I can't wait to share what you have learned about your site with others around Alberta, around Canada, and across the world.

Because your program is a star out there and deserves all of the kudos and credits, that you get. So thank you so much for taking the time, Tracee.

Tracee Pratt, Executive Director: Thank you Tara. And one more shout out. I could not be here and speak to this without the surgical team. Certainly Dr. Helen Steed has helped lead this. Our foundation partners led by Charlene Rutherford, the Royal Alex Hospital Foundation. Our surgical, our GYNE oncologists have all been part of that.

And of course our surgical team, Laurie Rakowski was the first person as a patient care manager that helped implement this. And she's retired now. But her leadership has also helped us get this. So the people that have gone before, the people that can continue to provide that excellence of care and constantly push us to think about, think outside the box and think what we can do next. It's all a huge thank you to them as well.

Tara Klassen, PhD: Thank you so much.

Tracee Pratt, Executive Director: Take care.