"The Ronan Report" provides insight about the activities at the Western Maryland Health System in Cumberland, Maryland, and about the changes taking place in healthcare today from a CEO's perspective.

Friday, October 31, 2014

The Flu

I couldn't resist writing at least one blog during the influenza season on the flu.  I find it almost amusing as to the fear that is being expressed over Ebola by those outside of health care.  Yet, many of these same people who live in fear of contracting Ebola are still opposed to getting a flu shot.  On average 36,000 people die each year from the flu and hospitals are inundated with hundreds of thousands of  patients with the flu or flu-like symptoms usually from December through February each year.  

Getting the flu is far more easier and dangerous than Ebola, at least at this point in time.  Many say, "no" to a flu shot, but when asked if they would get vaccinated for Ebola, they say, "of course."  Americans are funny people.  According to a New Yorker article on "Ebola vs Flu," we underestimate the risk associated with common perils such as the flu, but overestimate the risk of novel or remote perils such as Ebola.  Similarly, we worry about flying and subsequently dying in a plane crash yet, by driving our cars everyday, our chances of dying are almost equal to dying from the flu.  There are around 30,000 car accident deaths per year in the US.  

So, if you haven't yet gotten your flu shot, get one.  You owe it to yourself, your family, your co-workers and if applicable, your patients.  Also, your chances of becoming a statistic will be significantly reduced.

Tuesday, October 28, 2014

The New Scarlet Letter, "E"

I just read an article on Texas Health Presbyterian's (THP) drop in revenue since since October 1, 2014.  Their revenue was down 26% or $8 million dollars for the first 20 days of the month.  As you will recall, THP is the hospital where Thomas Duncan, the first patient diagnosed with Ebola in the US, first presented himself in the THP ED and subsequently died on October 8th.  Two nurses who cared for Mr. Duncan then tested positive for the Ebola virus.  They have since been released from the hospital.  

The THP ED visits are down 53% and their average daily census fell by 91 patients over the same period.  One of the OBs at THP reported that since October 1, 15 of his patients chose to deliver their babies at other hospitals and not deliver at THP.  If the lingering fears continue and patients continue to seek care elsewhere, this hospital may not be able to recover from such losses.  What a tragedy if that happens.

Monday, October 27, 2014

Do You Know What Could Be Done With $4 Billion?

Over the weekend, I read an article in the Washington Post as to the cost of the 2014 mid- term elections.  The total price tag is projected at $4 Billion.   That's right, "B" as in Billions.  Fortunately, when I watch television, it mainly consists of programming that I have recorded so I don't have to watch paid political advertisements.  But, when I do catch one on live TV, it's never about what the candidate will do if elected; it is an announcer talking about the horrible things that the candidate's opponent stands for.  In these commercials, the announcer is even gifted in using their best voice of doom when describing the opponent, but then the same announcer turns cheery once the candidate and his or her family appear on the screen. 

Early on in the election cycle, the candidates may focus on what they plan to do or what they have accomplished.  Quickly thereafter, the candidates and incumbents alike end up in the gutter trashing each other with out and out lies.  If we are lucky, we may get a half truth on occasion.  The entire process sickens me.  

Talk about campaign finance reform, I have some suggestions.  Instead of spending ridiculous amounts of money on campaign advertising, severely limit such spending especially if the ads are negative in nature. With the amount of legitimate hunger and homelessness in today's world, the need for greater interest in the pursuit of studies in science technology, engineering and math among our youth and the need to cure devastating diseases, wouldn't the $4 Billion be much better spend elsewhere than on paid political announcements?  Of course, it would, but as long as those seeking and holding office benefit from such advertisements, change will never happen.  

Friday, October 24, 2014

Treating and Caring For Ebola Patients in Maryland

Below is a message from Carmela Coyle, President of the Maryland Hospital Association, regarding the latest on the care of patients in Maryland who may have been exposed to the Ebola virus.  On behalf of the Western Maryland Health System, I want to offer my most sincere thanks to Governor O'Malley and Secretary Sharfstein on rapidly establishing a treatment strategy.  Patients will be initially evaluated and cared for in whichever hospital that they present until they can be transferred to one of three designated hospitals in Maryland / DC.  The first preference of treatment will be a one of four federal facilities, but if they are not available, Johns Hopkins, University of Maryland and Med Star Washington Hospital Center are the newly designated centers.  

Hospitals across the State continue to prepare, train, educate and drill should a patient with symptoms for Ebola present at an Emergency Department, but the designated center concept is a good one.  With these three hospitals, a greater focus can occur with equipment allocation, training and CDC support rather than trying to provide the preceding to 40 other acute care hospitals throughout Maryland.  Leadership acted quickly and correctly.

MHA Update, Friday, October 24, 2014

Thursday, October 23, 2014

Refinancing Our Bonds

In 2006, we financed the new hospital through a bond offering with HUD's FHA 242 Hospital Financing Program.  We went to the traditional rating agencies and couldn't get an investment grade rating at the time due to the amount of debt that we would be incurring.  HUD was more than happy to assist, and the process went much better than we had expected.  

The only issue was the continuing oversight of WMHS required by HUD's bond covenants.  They required WMHS to submit a number of transactions for approval, i.e. anytime we changed our bylaws, made a major change (like joining the Trivergent Health Alliance), etc.  Earlier this year, we began to pursue the refinancing of our bonds, although the HUD relationship was far less onerous than anticipated.  

We contacted Standard and Poor's and they agreed to assess WMHS for an investment grade rating.  Kim Repac and I presented to the rating analysts from Standard and Poor's in September, and we were approved for a BBB stable rating, which is investment gradeOnce the approval was received, a lot of work began between the WMHS team, our attorneys and our consultants.  Kim and I flew to Boston last week and presented to financial and investment analysts.  Then, the next day we did a webinar for analysts from all over the country.  Lots of questions regarding our perspective on health care, our value- based care delivery model and how it differs from volume-based care, and even some questions on Ebola.  

When we first presented  the concept of refinancingto our board, we were told by our consultants that we could expect a 4% savings, depending where the interest rates were at the time.  We set a target of 10%, which would have been around a $25 million net present value (NPV) savings.  By the time we went out to the market this past Tuesday, interest rates were very favorable and the result was a NPV of $47.1 million dollars or a 19.94% savings of refunding the bonds.  Through this refinancing, we will save WMHS $47 million over the next 20 years and reduced the average life of the bonds by two years and reduced our new hospital debt by $94 million from $333 million to $236 million.  All in a day's work!

Tuesday, October 21, 2014

That Was An Interesting First

I am currently attending a governance education meeting out of town with five board members.  At one of the breakout sessions on Sunday (The Total Cost of Health Care), the speaker was talking about value based care delivery being on the horizon for all US hospitals.  At the beginning of his presentation, he actually asked the attendees if they would be converting to value based care delivery at some point in the future or not.  I was surprised to see a number of hands that went up when asked if they were not.  (Are they in for a rude awakening?)

During his presentation, the speaker provided a few examples of some health systems around the country that are dabbling in value based care.  None of the examples were remotely close to what we are doing in Maryland.

After the session, I went up and introduced myself and explained what was going on in Maryland with value based care delivery.  I also relayed the experiences at WMHS over the last four years.  He was very impressed and asked if he could come and visit me in western Maryland. I said, "certainly".

This same speaker was then presenting the next morning to several hundred attendees at the General Session.  In the middle of his presentation, he asked where the attendees from Maryland were in the audience.  I, along with the five board members stood up.  He then started asking me questions about our care delivery model which led to me providing a detailed overview of Total Patient Revenue and value based care delivery to the audience.

The round of applause at the end of my overview was very nice.  There were a number of attendees who reached out after the presentation asking me for more information.  It was also interesting to be in different locations around the hotel yesterday afternoon hearing attendees talking about our model of care delivery at WMHS; some admiring the initiative that we took four years ago and others expressing a great deal of skepticism as to whether it would work in their hospital.  Interesting.

Friday, October 17, 2014

Have You Ever Lost Your iPad?

Earlier this week when I was in San Diego for a speaking engagement, I unknowingly left my iPad in the large hotel ballroom.  I had settled into my front row seat to hear our keynote speaker, Magic Johnson.  We then received word that he was going to be late because LA was socked in with fog so instead he would be our lunch speaker.  I then left the ballroom without my iPad and didn't realize until a few hours later that I didn't have it.  

After getting over that initial sick feeling that it was lost forever, I went to the Find My iPad app on my iPhone and began the tracking process.  The location came up immediately as being across from the hotel at Starbucks.  I remotely sounded the alarm on the iPad and made sure that it was also locked.  The iPad was then on the move further away from the hotel.  I sounded the alarm again.  I sent a message to the iPad with my cellphone number and another alarm.  Lo and behold as I started my trek to the lobby from the 35th floor, the tracking showed that the iPad was returning to the hotel.  I kept sending alarms.  

By the time I got to the Lobby, the tracking was showing that the iPad was back in the hotel.  I went to the front desk and asked about the iPad.  They didn't have it, but called Security to inquire about it.  The iPad wasn't in Lost and Found, but they would let me know if it was turned in.  I kept sending alarms the entire time, not sure if the alarm sounds and shuts off or keeps sounding.  

I then thought that I should go to the conference registration booth upstairs to see if they had it.  I sent another alarm just in case so I would hear it en route.  As I approached the registration booth, I could hear my iPad alarm sounding.  As soon as I walked up to the booth, they asked if it was my iPad and I said yes.  They said "thank God, the sounding of the alarm was driving them crazy."  I suggested that the next time they are in a similar situation, that they open it up and see the telephone number on the screen that they could have called.  They said that they hadn't thought of that.  We laughed and I was thrilled to have my iPad back.  

I never found out who had it out for coffee and a short walk outside the hotel, but quite frankly, I didn't care.  I had it back. The Find My iPad / iPhone app is a great addition and I would suggest that you familiarize yourself with it just in case.

Thursday, October 16, 2014

WMHS Is Ready—Just In Case

WMHS, like all hospitals and health systems across the country, is following the evolving situation surrounding the emergence of Ebola in the U.S.  As part of our continuous emergency preparedness planning, our team had already developed a response plan for a possible case of Ebola coming to our health system.  That plan was based on the  guidelines established by the CDC at that time, and the team was getting everything in place for an appropriate response.  

Since the first Ebola patient was identified in Texas, our team has accelerated its efforts to have us ready.  Our team is constantly monitoring the CDC’s advisories and is in close contact with state and other federal health agencies.  It is meeting regularly to update our plan as new information becomes available, making sure our plan is consistent with the latest guidelines.  

Our staff is accustomed to following strict infection control and prevention procedures and we have the necessary personal protection equipment (PPE) available.  The readiness team quickly developed additional training for physicians and staff to practice the proper way to put on their PPE and safely remove it.  We also are using the “buddy system” where a co-worker monitors the process to ensure the right procedures are followed.  Over 100 employees have already gone through the training over the past several days.  

WMHS is committed to maintaining the highest standards and most current protocols to minimize the risk of anyone contracting an infectious disease like Ebola.  I want to recognize the many members of our readiness team for their hard work to get us prepared for this and similar situations.  It is an exemplary group of professionals who are dedicated ensuring the health and safety of our patients and our caregivers.  

Wednesday, October 15, 2014

SHSMD San Diego

This past weekend I had the opportunity to participate in the annual conference for the American Hospital Association's Society for Health Strategy and Market Development.  I was invited to serve on a Thought Leader's Panel for senior executives with three other individuals.  I was thrilled to serve with Dr. Henry DePhillipe, the CMO of Teladoc, and Lynn Miller, the EVP for Clinical Services at Geisinger.  The three of us had a great time, along with two senior executives from Kaufman Hall.  They are all exceedingly bright people; what an honor for me.  

We each had the opportunity to present background on ourselves as well was what we were doing to keep viable as a health care provider in an ever changing environment.  Of course, I presented on our journey from volume-based care delivery to value-based care.  As has been the case for the last year, the information was very well received.  We then were asked a question by our moderator about our perspective on the changes in health care, which gave me the opportunity to talk about the many initiatives that we are engaged in related to our new care delivery model at WMHS.  Again, very well received with lots of great feedback.  

The floor was then opened for questions.  During our pre-session lunch, our moderator expressed concern that I would get the bulk of the questions based on the uniqueness and success of our journey into value-based care.  However, he did a nice job of making sure that we all had the opportunity to participate.  There were several "crystal ball" questions based on what we know now and what can then be expected in the future.  The attendees had a lot of great questions and also offered some wonderful perspectives related to our various topics.  

In fact, after the session, the moderator asked if I was publishing our journey into Value- Based Care Delivery.  I said not at this time as there are too many things going on.  He said that I would be doing a disservice to the health care industry if I chose not to write a book.  Of course, I took that as a compliment and have started to think about the idea.  Anyway, it was time very well spent, and to be able to do it in San Diego with most of my expenses paid was certainly a bonus.

Tuesday, October 14, 2014

Blinded By the Light

The other day, I heard a national radio interview with a nurse who was leaving for West Africa to care for Ebola-infected patients.  She said that she was called by God to be there.  She said that she told her family that she had to go so please support her in her decision. She never asked for their permission, only their support.  

I certainly don't know her personal circumstances, but if I was faced with the same situation and my wife, a nurse, said that she was called by God, I would have trouble supporting such a calling, at least under the current circumstances in West Africa. I guess that I know too much.  I have read numerous accounts and have seen footage of what is happening in West Africa in the care and treatment of these patients. The conditions in which these people are being cared for are primitive at best.  They lay on rugs on dirt floors in large huts with scores of other infected patients around them.  There is an extreme shortage of gowns, gloves, masks, face shields, water, hand sanitizer and the list goes on.  

This nurse is going there for all of the right reasons but could be failing to grasp to gravity of the situation, well at least until she arrives.  God speed to all who find themselves in a similar situation.

Monday, October 13, 2014

Thrown Under The Bus

That sound you just heard was the newly diagnosed Texas Health Resources nurse who now has a confirmed case of Ebola, as well as the entire Texas Health Resources organization, being thrown under the bus by the Director of the Centers for Disease Control.  While he was at it, he either intentionally or unintentionally took the opportunity to throw the other 4999 US hospitals under the bus, as well.  

He told the world that the second contraction of Ebola in the U.S. was because of a breach in protocol, i. e. poor technique by a health care worker who is a nurse and a trained professional. Now the CDC is going to work with hospitals to teach us how to properly gown and glove.  

There were a whole lot of other ways the CDC could have handled this reported exposure, but they chose the "the bus route."  You gotta love politics.  The Director's self-proclaimed "tell it like he sees it" approach fails to mention that he is following the Administration's policies at whatever cost.  I can understand not wanting to create panic across the U.S., but maybe understand the situation a little better before declaring that hospitals don't know what they are doing, which seemed to be order of the day yesterday for ABC, CBS, NBC and CNN. 

Also, who better to deal with such matters as isolation, quarantine, worker and patient protection than hospitals, etc.?  This same government now has 4000 troops and Public Health Service members in or en route to west Africa to work directly with Ebola patients and their current caregivers.  Do you really think that the military and the US Public Health Service have thoroughly trained these individuals to follow their "well established" protocols; they haven't.  

One would think if you are with the Public Health Service that you would have the knowledge and background to deal with such situations.  They  are very well trained in many aspects of health care and medicine, but not the care and treatment of Ebola patients.  Everyone is getting a crash course.  These Public Health officers are coming out of federal prisons, off Indian Reservations and out of federal government offices such as CMS, FDA and CDC.  The same with the military; a crash course for the great majority, but yet hospitals that deal with similar exposure and subsequent isolation situations daily, maybe not as deadly as Ebola, are being criticized by the CDC for failing to follow protocols.  

How about stopping the travel out of west Africa, reserving judgment on the work of trained professionals, giving all US hospitals what they need to best care for and treat Ebola patients, designating some hospitals as super centers across the U.S. for the extended care of such patients and establishing the necessary regulations for the safe handling, transportation and disposal of Ebola waste rather than on a case by case basis.  You have had months, if not years, to have been working on this and so far very little has been done.  

Thursday, October 9, 2014

A Step By Step Guide To How Hospitals Discourage Doctors, Really?

I read a blog last week from a midwest physician who posted on KevinMD's blog page.  I am a regular subscriber to KevinMD and it has proven to be a great blog especially for physicians.  

This particular blog was about a radiologist who was waiting to see someone in administration and he finds a document that was left by a vendor / consultant.  The document was entitled, "How to Discourage a Doctor".  According to the radiologist, the document provides hospitals with tactics and proven strategies on how to better control physicians in their hospital.  He describes the contents which suggests that hospitals introduce barriers to the physician's care, increase their responsibility while decreasing their authority, no longer allow them to meaningfully influence health care decisions, promote a sense of insecurity among the medical staff, convince them that their professional judgement is no longer reliable, make health care incomprehensible through information technology, show physicians that they are no longer important in the care delivery model, transform all independent physicians to employees, insist upon the use of broad practice guidelines and subject physicians to escalating productivity expectations.  

What the blog did for me was to give me a good laugh.  When I first read the blog, I thought that it was a joke.  So, my reaction is as follows: first of all, the garbage that comes across my desk or finds it's way into my email box throughout the day from vendors/consultants is immeasurable.  Everyone's got an angle which would certainly be the case for the consultant who left this particular document.  If there are health care executives following these suggested tactics and strategies, they won't be around for long.  

Based on changes in health care today and going forward, hospitals have to find ways to better integrate physicians into the ever changing care delivery model.  If anything, the physician's role is more critical as we work to put the patient in the center of everything that we do.  Are their changes impacting hospitals and physicians, most certainly.  Are these changes at the expense of the physician, absolutely not.  We are constantly looking for ways to get the physician more involved with what we are trying to accomplish.  There are regulations and requirements that are being heaped upon hospitals (and soon to be heaped upon physicians), but we can only be successful if physicians and advanced practice professionals are part of the team.  

For example, with new IT systems, we are only as good as the extent of our medical staff's involvement in bringing such systems up.  Are we using protocols, we are and when a physician arrives who had been trained in using such protocols, you can't get them to deviate from them; they have a place in the new care delivery model.  Are we pushing physicians to be employees, nope.  We will work with them if they are interested, but employment is not for every physician.  We seek common ground for physicians who are looking for a different practice model.  Are we escalating performance expectations, we are for our employed physicians, but at the same time incentivizing them accordingly.

I certainly hope that the many physicians who read this radiologist's blog don't believe what this particular consultant was promoting, but if they do, they need to sit down with a member of the C-Suite with whom they are most comfortable and discuss the contents of the document.

Tuesday, October 7, 2014

Finally, A Study That Says Pot Is NOT Harmless

Professor Wayne Hall, a drug advisor to the World Health Organization, recently completed the results of a 20-year study on the effects of marijuana usage.  Some of his findings are as follows: 

  • The drug is not safe. 
  • One in 6 teenagers who use it regularly will become dependent on it.
  • Usage doubles the risk of psychosis, such as schizophrenia.
  • One in 10 adults who use it regularly will become dependent on it and it will lead to use of harder drugs.
  • Smoking while pregnant will reduce at minimum the baby's weight and impact its ability to thrive.
  • After smoking it and then driving, the risk of an accident is doubled.
  • It is harder to stop using than heroin.
  • Long-term use increases the risk of heart disease, cancer and respiratory disorders.
And his main finding is again the impact on teenagers; those who use it regularly can have mental disorders and addiction issues. The lone bright spot of the study was that it is less dangerous than heroin or cocaine in the risk of sudden death since you cannot take a lethal dose of marijuana.

Now, if you listen to Hollywood, liberal politicians and even our President, marijuana is not harmful, it should be decriminalized, legalized and ultimately, TAXED.  I agree with the decriminalization aspects.  It is ridiculous to have one state treat possession of a small amount as the equivalent of a parking ticket and another state  treat the amount as a felony.  Our President, who is a self proclaimed past user of marijuana, views it as a bad habit, liking it to smoking cigarettes, and says that it is no more dangerous than alcohol.  That may be true, but we all know that there are dangers associated with the use of alcohol, especially in excess, but to date we keep hearing that marijuana use is harmless, at least until now.  As a side and "to offer comfort," the actor, Jack Nicholson, said back in 2011 that he is a regular, but responsible user of marijuana......I rest my case.

Friday, October 3, 2014

My Concerns Regarding Ebola Continue to Grow

As the Centers For Disease Control continue to attempt to reassure the American public that there is nothing to worry about now that we have our first confirmed case of Ebola in the US, quite honestly, I feel that there is a great deal to be concerned about.  One can certainly start with the waste that is being created in the care and treatment of the patient in Dallas and the two patients who preceded him in Atlanta.

It appears that no one has told the Department of Transportation that they need to act "quick and in a hurry" on changing their regulations on the safe handling, transportation and disposal of products used in the care and treatment of these patients.  Right now, hospitals are pretty much on their own as no company that deals in hospital waste is permitted to handle Ebola waste at this time.  The hospital in Atlanta was forced to have their staff go to Home Depot stores throughout the city and buy all of their 30 gallon drums to store the waste.   Hospitals and public health agencies have been under the gun to gear up for Ebola while the DOT has done what appears to be little in addressing handling, transportation and disposal of Ebola waste.  

Then there is the demand associated with hospitals across the US in acquiring key items such as gloves, masks, linens, special supplies and equipment to be prepared for patients exposed to the Ebola virus.  With 13,500 active US visas from Liberia alone; all 5000 of US hospitals have to be prepared.  Since travel is not restricted from Liberia or west Africa, anyone of these people could walk through our doors at anytime.

It has already been determined that the Dallas patient from Liberia lied on his health application in order to travel to the US.  How many more are out there who will do whatever it takes to get to the US for treatment after an exposure? The gearing up will create immediate shortages not to mention the cost of acquisition for which we are pretty much on our own.  

Then there's the concern that no one wants to talk about which is using infected patients or their waste products are weapons for terrorism.  My opinion is that hospitals, public health agencies and even government need more time to prepare for this epidemic and the residual impact that this will have on our country.  Day to day, there is a lot that goes on with government that concerns me; this issue scares the hell out of me!

Thursday, October 2, 2014

A Series of Teachable Moments

In recent days, we have learned of the first confirmed case of Ebola in the US.  A Liberian man flew from Liberia in West Africa to Brussels, Belgium, then to Dulles Airport in Virginia and onto Dallas, Texas.  He came to this country to visit his girlfriend, who is also the mother of one of his children; she has four other children, as well.  

Shortly after his arrival, he fell ill and went to the ED at Texas Health Presbyterian in Dallas to be seen.  The appropriate CDC protocols for Ebola were followed as a part of his triage as it relates to questions being asked regarding his travel.  However, the RN failed to communicate that he recently came from Liberia or the provider in the ED failed to pick up on this critical piece of information.  The patient was never admitted and subsequently discharged with antibiotics.  

Two days later, he returned to the same ED, this time via ambulance, and eventually tested positive for Ebola.  In that two-day period, he was exposed to many members of his girlfriend's family, including her five children who went to school after being exposed to the patient.  The authorities are still trying to determine the extent of the exposure including other family members, members of the community, the EMTs and unsuspecting health care providers.

Now for the teachable moments, first the communication in the ED.  I can't imagine how the intake RN and other providers feel at this point in time after not sharing or picking up on a critical piece of information regarding this patient.  The second teachable moment is with the US government allowing unrestricted travel to and from a hot zone like Liberia and other hot zones for Ebola in west Africa.  Third would be the US airlines that have not ceased travel into and out of these hot zones.  I am not sure what their reasoning is, but they have the potential of putting a lot of people in harm's way by not following the lead of other international carriers who have suspended such flights.  The reason that the US government has given for not restricting travel is the criticality of commerce to and from that region.  Really?  

I would feel a whole lot better if public health had more experience in managing Ebola exposures and preparation for ongoing exposures, which they will acquire over time but more time is needed.  With unrestricted travel to the US, there will be a burden that will eventually impact public health and health care in caring for and protecting the general public from exposure. There needs to be greater protection of Americans on the part of those who can do something about keeping us safe going forward.  There are  quite a few lessons that can be learned from this exposure; hopefully, common sense will prevail and changes are imminent.

Wednesday, October 1, 2014

You've Made My Day

This morning while I was on rounds throughout the hospital, I stopped to talk with one of the nurse managers.  She told me that one of her staff nurses included in the comments section of her performance evaluation that she wanted to sit down and have a cup of coffee with the CEO.  The nurse asked the nurse manager if she could arrange that.  The nurse manager said that she would try.  

Well, it just so happened that this particular staff nurse was working today.  I had the opportunity to meet and briefly chat with Kiea Barnes.  She said that she had heard so much about me and wanted the opportunity to meet me and to sit down and have a cup of coffee.  I asked her if a cup of tea would work and she said of course.  It was a very pleasant conversation, ending with her saying that meeting me made her day.  I told Kiea that she certainly made my day as it was very kind of her to want to sit down with me just to talk.   And talk we will; arrangements are  already underway for our chat.  

I was told many years ago by my predecessor that when it comes to how people view a CEO, they see you sitting on top of a flag pole.  One group looks at you and admires what it took for you to get up there.  The second group says that you are crazy for being up there and the third group tries to shake the pole to get you to fall off.  Kiea is certainly in the first group and it is very much appreciated.  I am so fortunate to have such a wonderful group of employees like Kiea who support what we are trying to do each day to advance care delivery in our community.