Kevin Tabb 0:03
Listen to your people, empower them to do good things, break down barriers where they exist, and get out of the way.
Gary Bisbee 0:15
That was Dr. Kevin Tabb, president, and CEO Beth Israel Lahey Health, commenting that leadership fundamentals are in effect during a crisis or any other time. I’m Gary Bisbee and this is Fireside Chat. Kevin brought us up to speed on the current COVID surge, which he describes as a “surge on a surge,” an expression that he attributes to Dr. Tony Fauci. He discussed lessons learned from the first surge and how patient-facing caregivers, which are approximately 60% of BILH employees are handling the grinding and steady pressure. He shared positive progress on vaccinations among BILH employees and that in a survey, 70% responded positively to taking the vaccine. Strategies to approach the 30% who did not respond are underway. Kevin went to medical school and fulfilled his residency in Israel and he discussed the commitment to public health that makes vaccine distribution so successful. For example, after two and a half weeks, 50% of the 65 and overpopulation of Israel have been vaccinated. Kevin shared his view of how the pandemic is changing the roles of C-suite leaders. Let’s listen to his thoughts about the effect of the pandemic on the CEO role.
Kevin Tabb 1:35
The CEO role cannot be simply being reactive. And I think many of us find ourselves right now right in the midst of a wave naturally being reactive. But we’ve got to move back to thinking about moving the organization in a direction that will be impactful long term.
Gary Bisbee 1:57
Kevin dug into the effect of the fast-moving decision cycles with the pandemic and how they are affecting the health system strategy.
Kevin Tabb 2:05
The danger is that we continue to hew to a strategy that might have made sense three months ago but might make less sense now. So finding that balance of understanding how things are changing, changing our own outlook, getting out ahead of the curve, I think that’s at the heart of having a good strategy.
Gary Bisbee 2:26
I’m delighted to welcome Dr. Kevin Tabb to the microphone. Well, good morning, Kevin, and welcome.
Kevin Tabb 2:36
Thanks, Gary. Good to be here.
Gary Bisbee 2:37
We’re pleased to have you at the microphone for the second time. So we appreciate that very much. Everyone is talking about COVID these days whether they’re inside or outside of healthcare. How is the surge in Boston and how is BILH faring?
Kevin Tabb 2:52
We are definitely seeing a significant surge and Tony Fauci called it a “surge on a surge” and I think that that’s exactly what we’re seeing in Massachusetts and around the country. For us, we saw a significant steady rise, particularly after a combination of Halloween and Thanksgiving. Things plateaued a little bit but didn’t drop. And then we now have layered on it this next surge. And what that meant for us is that in the last two weeks of December our system saw a 44% increase in COVID hospitalized patients in two weeks. So it’s just been an explosion. And I would say a lot of that really doesn’t have the full effect of Christmas, not to speak of, New Years’ baked into it. The other major difference between this wave and the previous wave is that in the previous wave the hospitals really emptied out. Now, people that should have gotten care for non-COVID diseases really didn’t come in and get their care. That’s not a good thing. But the hospitals emptied out. And we had maximum flexibility in terms of space, but also in terms of staff to move things around and take care of a large number of COVID patients. It’s really different this time around. Our hospitals are full of very ill non-COVID patients. And then we’re layering into that a large surge of COVID patients. And so the combination of the two means we are now past the high watermark that we were at in the first peak when you have total number of patients that were taken care of. And at the same time, we have fewer staff available because we’ve got over 800 staff that are out quarantined, either with COVID themselves, or having had contact with somebody with COVID and so it’s a difficult situation.
Gary Bisbee 4:51
Did you learn lessons from the first surge about treating patients? Are things more efficient now or about the same?
Kevin Tabb 5:01
We all learned a great deal about how to take care of COVID patients and I think we’re better at it now than we were before. It’s probably a combination of having more comfort with those patients, doing things like proning them earlier, keeping them on high flow oxygen, and not intubating them until much later in the process, as well as a use of dexamethasone and other treatments if they get to the point where they’re really, really sick. And the good news there is that the percentage of patients that are hospitalized with COVID that need ICU care is lower than it was in the first wave. The first wave we saw somewhere between 35 and 45% of the COVID patients ending up in the ICU. We seem to now be steady at about 20% of the COVID patients that are hospitalizing needing the ICU. That’s better, of course, but it’s still a problem because as the numbers rise, the denominator is very large and we need to take care of now very sick patients on med surg floors, in ways that we’ve not traditionally been used to.
Gary Bisbee 6:05
Talking about your 800 staff short brings to mind, what kind of effect is this having on your frontline troops? You begin to worry about the sustained pressure that they’re under.
Kevin Tabb 6:17
They are under sustained pressure. And we are very worried that they’ve been working nonstop. They’re tired, they’re worried that they are at personal risk themselves, although I think we’re doing everything we can to protect them. And many of them are traumatized by the experience that they’ve already been through, even as we ask them to do more. One of the additional challenges I think that we see is many of them are asking themselves, “We’re doing all of this. Why can’t everybody else do a little bit more to shut down, to wear their masks, to socially distance?” And it’s extraordinarily frustrating for people who come in day in and day out and take care of these really sick patients to see that and wonder whether everybody is in this together?
Gary Bisbee 7:03
I can see that. Well, the segue to vaccines is natural here. How is that going? Do you have enough supply? And what’s the declination rate of your staff?
Kevin Tabb 7:15
The vaccines are definitely a light at the end of the tunnel for us and a source of great excitement among healthcare workers and a real morale boost, no question. At the same time, we don’t have enough vaccine. And it isn’t rolling out quickly enough. I think that what science has done to produce the vaccines that they have in this short of a period of time is nothing short of amazing. The challenge is not a scientific challenge. The challenge is a supply chain challenge and one of general inefficiency at the federal level. And so we know there are doses available that are simply not getting out to the state. That being said, once they get to us, we’re doing everything that we can to get every last vaccine in people’s arms as quickly as we can. So when we look at our own workforce, we’re first, in this state, we’re vaccinating healthcare workers first. And we’re only vaccinating those that are patient-facing. That’s about 60% of our workforce and we have vaccinated close to 15,000 of our workforce in about two and a half weeks. The declination rates are very low, but that’s a little misleading. So we send out an invite for people to schedule, those that are eligible. And of those that respond, only 4.5% have declined and said that they don’t want to be vaccinated. And that’s a very low declination rate. The problem is, is about 30% of the people that we have offered it to have simply not responded. And we think that that is probably buried within that 30% is a much larger, silent declination rate. And that’s going to require work on our parts. The thing that’s perhaps most disturbing to us is when we analyze those that haven’t responded and gotten vaccinated, even though they’re eligible, there’s a disproportionate representation of people of color. These are folks who are at highest risk. And we need to work very hard to make sure that we’ve done everything we can to allow them to understand fully what it is we’re offering and get them the vaccine. So we’re working hard at that.
Gary Bisbee 9:31
Are there any other support programs, local, state, I’m not aware of anything nationally that would help approach some of the minority community about vaccinations?
Kevin Tabb 9:42
There absolutely is. There’s a concerted effort in this state to get to communities of color through everything from local community leaders to people in churches and other things. I think though, at the same time, what we find is people respond the most to people that they personally know and trust. We find within our own organization if we go down and talk to a patient transport who’s exposed constantly, and say, “You know what? Somebody else who was a transporter got the vaccine, didn’t have a reaction, thinks this is something that he/she should get. And oh, by the way, we’ll take you right now. We won’t put in place bureaucracy, we won’t tell you you need to schedule on a computer, to come up right now, we’ll vaccinate you.” That’s the kind of thing that we need to do to raise these numbers.
Gary Bisbee 10:34
Why don’t we turn to Beth Israel Lahey Health? The merger now is almost two years old, but half of that time has been with COVID, so probably seems somewhat unnatural. But what’s the update on the merger, Kevin?
Kevin Tabb 10:50
Notwithstanding COVID, the merger has gone extraordinarily well. So we look at how we were doing up to the pandemic, we were exceeding many of the goals that we set for ourselves clinically, financially, integration goals, and other things. And then COVID hit. Ironically, what COVID did in many cases was it accelerated our integration rather than the other way around. I had a couple of CEO colleagues who said to me, “Boy, I don’t envy you just having just done a merger and now COVID. It must be a disaster.” And my response actually was that the pandemic forced our hand in a good way to behave as a system in service of our patients and the communities we serve. And that had some really specific meanings in the context of COVID. Given that Beth Israel Lahey takes care of somewhere between 20 and 25% of the COVID patients in the state, if we had continued to act in silos in the way that we did, we would quickly have found our institutions overwhelmed on their own. We found some sites with PPE, some sites without PPE, some of our institutions who sit in underserved communities were disproportionately impacted, they would not have been able to deal with this as well on their own as we were able to do this by behaving as a system. And so, if there is a silver lining, I think that’s one – we won’t go back once we get through this pandemic
Gary Bisbee 12:20
Scale matters. Does this suggest that there might be further M&A activities for BILH?
Kevin Tabb 12:27
I don’t know the answer yet because it was noted in the press that we are in discussions to bring Joslin Diabetes Center into our network. And I think that that will probably occur sometime this year. We’re always open to additional opportunities, but we don’t grow for the sake of growth. We don’t grow just to get big. We find in fact, more often than not at this point, perhaps because of the pandemic as much as anything else, that people are knocking on our door asking if they could become part of the system. And not in every case does it make sense for us. I think we’re trying to do this in a careful fashion that makes sense. We understand it’s really hard out there for small, independent hospitals. Certainly across the country the wave of mergers and acquisitions that we’ve seen for the last few years, I believe is going to accelerate significantly as a result of COVID.
Gary Bisbee 13:22
You went through a number of regulatory barriers for this transaction. Can you really continue to expand locally or would you have to go to some kind of regional network?
Kevin Tabb 13:33
Well, we’re under a lot of scrutiny. We were under a huge amount of scrutiny prior to the transaction that we conducted two years ago. And that’s scrutiny at the state level by the attorney general by the state, that’s scrutiny at the federal level also. And ultimately all of the bodies agreed that the transaction made sense. But we had an unprecedented number of restrictions put on us – caps around a host of things and commitments that we needed to make to underserved communities, and anything additional that we would do would undergo itself a fair amount of scrutiny. We are hearing that the agreement that we ultimately came to with the regulatory bodies to allow us to move forward is now potentially being used as a model for attorneys general around the country. And I’ve certainly received some calls from folks asking what exactly was in the agreement and how did that work. So others are looking at this transaction potentially as a model.
Gary Bisbee 14:35
Let’s go back to COVID. What effect has this had on particular executives, let’s just say chief medical officers of a large health system like BILH. Is their role going to change going forward because of COVID?
Kevin Tabb 14:51
The Chief Medical Officer at BILH has taken on an outside role and he really runs now all of the coordination as it relates to COVID, all of the moving back and forth of patients really in conjunction with the disaster preparedness folks. This is a person, the CMO, along with his team, that are really at the heart of what we’re doing. I think that will continue beyond pandemic and the change will continue because what happened very quickly was people understood how important the CMO role was in behaving as a system in a very concrete fashion. Where if we had not had COVID, it would have taken years for him to get the trust of and the understanding of what a CMO does. Everybody knows now – everybody knows who to call, everybody knows what to talk about, and I think that will continue on beyond the pandemic.
Gary Bisbee 15:43
What about the CEO role? Do you see that changing or evolving over the next several years due to COVID?
Kevin Tabb 15:49
Well, I think the CEO role was and continues to be, I hope, one particularly of understanding and crafting a strategy beyond the art of the things we do on a day-to-day basis. The pandemic has forced us all to take a pause and deal with very much the day-to-day running of the system, which is important, and what we need to do right now is to make sure that we have the pieces in place to deliver the care we need. I think we’re all hoping to be able to get to the point where we can lift our heads above it again and think out beyond. Because a CEO role cannot be simply being reactive. And I think many of us find ourselves right now right in the midst of a wave naturally being reactive. But we’ve got to move back to thinking about moving the organization in a direction that will be impactful long term. And that isn’t static either, the idea of what that direction will be. I think one of the major dangers particularly now is that as we reach an inflection point in how healthcare is to be delivered, and really see change in all of this in many aspects of our lives, the danger is that we continue to hew to a strategy that might have made sense three months ago but might make less sense now. So finding that balance of understanding how things are changing, changing our own outlook, getting out ahead of the curve, I think that’s at the heart of having a good strategy. And I’d say, as an aside, so many of us can be paralyzed by the desire for perfect information and exact data, predictability on what’s going to happen. And as much as I would like for there to be perfect information for me to have so that I can craft the, quote-unquote, “perfect strategy,” whatever that is, we’re not going to have it. And we cannot be paralyzed into inaction because of the absence of perfect data, particularly in a time like this.
Gary Bisbee 18:01
Well, it’s an easy transition to think about the governance process given what you’re saying about the CEO role. How are you thinking about the role responsibilities of the board of directors, Kevin?
Kevin Tabb 18:13
The board of directors obviously needs to provide oversight and good governance. The board of directors should not be involved in the day-to-day operations or management of an organization. I think the role of the board will be to continue to press us as a leadership team, to make the case for how we continue to serve the needs and missions that we have, right in the midst of the pandemic we’re facing and for many years to come. And the board of directors needs to make sure that it continues to ask questions that you yourself, Gary, are asking of us. Are we best serving our missions now? How does what is happening now change the way we need to think about our missions in the future? And certainly, those are questions that my board is asking.
Gary Bisbee 18:57
Thinking about how COVID is going to affect our large health systems going forward. If you could just isolate, let’s say, on some midterm, the next three, four, five years, what do you think is going to change due to COVID that would be maybe built on a past trend, but is really going to respond specifically to COVID? Anything come to mind there, Kevin?
Kevin Tabb 19:24
Everybody of course talks about things like telemedicine and the shift to telemedicine, there are payer shift mix and other things, but I think that those are smaller signs of larger trends. I believe that systems will need to both get larger, but to behave more as systems. We won’t be able to continue down the current path of everybody acting on their own, either because we’re part of different systems or because we’ve got all of these entrenched silos within our systems. It’s not efficient and it’s not safe. And yet we’ve allowed, through inertia or other things, for that to be perpetuated for a long time. So the best systems in the country that have been doing this for a long time are very good at behaving in an integrated fashion. But the honest truth is that we could count on the fingers of maybe two hands, out of all of the hospitals and systems in the country, systems that really behave that way. We’re going to need to accelerate our acting in a coordinated, cohesive fashion. That is going to be the biggest change. And those that do, will do well and will do well by their patients. And those that don’t are going to falter big time, I think.
Gary Bisbee 20:37
As you talk to your CEO colleagues is that a generally accepted understanding?
Kevin Tabb 20:43
I think it is. I think that there are different ways of approaching that understanding. And that’s legitimate too. I think the idea of how to organize yourself as a system and what that means, it’s legitimate to say there are different ways to get at it and there is no one best way. I like to keep my eye on the ball, which is ultimately how do we measure ourselves? And have we made a difference in people’s lives? And I actually believe there are ways to measure that. But I don’t think there’s anybody that would suggest that we can or should continue to behave in a vulcanized fashion, which really characterizes American healthcare. I have to say, this idea that it’s a cottage industry of many vulcanized pieces that don’t talk to each other, that’s a recipe for replication of many of the disasters we’re seeing now.
Gary Bisbee 21:31
Of course, you went to medical school and did your residency in Israel. Is there any guidance from how the Israel health system is organized that we could draw on here?
Kevin Tabb 21:40
Well, I think you do see now a very concrete example of how having universal coverage, it’s not single-payer by the way, but universal coverage, so everybody who lives in the country is covered by healthcare combined with significant investment in public health infrastructure is having a massive effect on their ability to do things like roll out a vaccine really quickly. Israel is now number one in the world for vaccination of a population on a per capita basis. Israel in the space of two and a half weeks has vaccinated 10% of their population and over half of the population over the age of 65 -in two and a half weeks. Israel believes that by the end of February their entire population will be vaccinated. Now, they’re a small country and people might say, “Well, okay, but 8 million people, that we could do that, that’s in a metro area.” And that’s true, but they have fewer people to get all of this done. They have a public health infrastructure, they’re rowing in the same direction, everybody’s covered, and they’re getting it done. And we’re gonna need to do things like that here too.
Gary Bisbee 22:49
Well, we’re starting to understand now, finally, after years of ignoring public health that it’s directly related, really, to the security of the country, to our economy. How do you, just in terms of talking to the people you talk to, policymakers, CEO, colleagues, is there some kind of general understanding of that? Do you think that there’s a movement to upgrade our public health infrastructure?
Kevin Tabb 23:14
I’m not going to go as far as to say there’s a movement to upgrade the public health infrastructure because that would require funds and movement at the federal level. I think there’s a unanimity of understanding of the importance of that in the healthcare community. The question is whether or not that will translate into legislation and funding. We’re certainly going to continue to push for it. I can’t imagine, if COVID doesn’t make the case for us doing that I don’t know what would. But we’ve seen again and again that not everything that makes sense happens in the short term. So we’ll continue to push.
Gary Bisbee 23:54
Let’s go to affordability which is a term that’s a pretty broad term, but many people think this decade will be the decade of us addressing affordability as a country. How do you think about that, Kevin?
Kevin Tabb 24:08
I agree. I think that the path that we’re on has long been unsustainable. And there are a lot of components of that. But it’s not sustainable to spend 18.5-19% of GDP and continue to rise and go to 22 and go to 24. You know, at some point, it’s a house of cards. I think that there are a fair number of components to affordability in healthcare and the high cost. Providers themselves have some responsibility for it. We certainly don’t have the only responsibility for it. But I would suggest unless we take responsibility for our piece, it’s very hard to go to others and say you need to take responsibility for your piece. So I think we have a responsibility to do our part to both provide more transparency and accountability around the care that we provide at a reasonable cost. And the trajectory we’re on isn’t sustainable. But even if we did all of that, even if providers did it, but did it unilaterally, it would not be enough to bend that curve. Unless there were a fair number of other pieces of this pie that came together to ultimately bend the curve.
Gary Bisbee 25:17
What about the new transparency regulations to publish prices? Do you think that’s going to be useful at all?
Kevin Tabb 25:24
I don’t. I think very few people will use it or understand it. And I think there’s no evidence, no history of that sort of thing having significant impact. I’m not hugely against it. I think it’s got its own problems. I’m not terribly concerned about it. But I also don’t believe that it will be a real force for change.
Gary Bisbee 25:46
Can we take significant steps to affordability with the current arrangement where the providers are cost-shifting to the commercial entity from the governmental entity?
Kevin Tabb 25:58
That is one of many challenges. All money is fungible and if you are losing money on one part and you’re making it up on another, in the end, you add it all together and we’re all trying to keep our heads above water. But we’re going to have to, as providers, find ways to be less expensive and more efficient. Again, I just want to point out, even as we do that, though, that isn’t going to be enough. We see pharmaceutical costs skyrocketing, we see a host of other things happening that are also contributing to this.
Gary Bisbee 26:30
There’s a term “the new middle” that some are using to approach the fact that if there was either a partnership or some ownership between the financing functions and the delivery functions, i.e. between a health plan and a health system, that that would move us down this path toward value and be more affordable. How do you think about that, Kevin?
Kevin Tabb 26:54
I think it’s possible. I’ll say, we’re trying to find a lot of ways in this country to get at this. It’s not the way that most other countries in the world have gotten at it. And so I think we have struggled with allowing the free market to fully determine what cost is, which is, again, different than any other country in the world as it relates to healthcare.
Gary Bisbee 27:16
Seems like there’s a shift from the payer and insurer to the provider and consumer, a shift of health risk, we could call it, that is putting the provider in a pretty difficult position, would you say?
Kevin Tabb 27:30
Absolutely. So what you’ve seen is a shift to the provider without any additional tools or funding for that a shift of the risk. And what you see not infrequently is a further shift then to patients. And this idea that, well, if a patient just has, quote/unquote, “skin in the game,” that’s actually a term that I can’t stand as it relates to healthcare, but they’ll just make, quote/unquote, “rational decisions,” I think, is a fallacy. I think people make rational decisions, but they don’t have information available to them. It’s very difficult to understand what your best choice is. And it’s not an irrational decision to put off preventative care and other things if you need the money to pay for groceries or keeping the lights on. And all of those things are rational decisions. But simply by pushing the risk and the copay to thousands and thousands of dollars to patients, I’m not sure we’re going to see the effect that we would like to see.
Gary Bisbee 28:28
When you started at Stanford you started as a chief medical information officer before becoming the CMO. But you’re ideally positioned to comment on the effect of the HITECH Act and all the digitization of medical care in the last decade. How’s that going to affect everything from affordability to efficiency to scientific innovation in this decade, would you say?
Kevin Tabb 28:53
We have made a leap forward and it’s fashionable to criticize, and I understand it, the downsides of IT and healthcare IT. And IT is certainly not the savior of the healthcare system, but I think we’ve made huge leaps forward in the last decade. I mean, it was a decade ago that many health systems simply didn’t have certified EHRs or individual physician offices didn’t have them at all. We’re well past that now. But I don’t think, again, that healthcare IT is in and of itself going to be the solution to our problems. It’s a way to help us get there, but it’s not a panacea. And I like to point to the use of OpenNotes as an example of something that I think is really helpful. So OpenNotes, the movement to requiring everyone to have access to their own records electronically, the full record, not a summary of, but everything that was written about. That’s not a new feature. You don’t have to roll out a new EHR to do that. You don’t need to get a new company to do that. That’s a policy. That’s a policy that’s supported by the fact that we now all use electronic health records. But I think it’s a policy that might potentially have a bigger effect than many other things. And that’s just an example.
Gary Bisbee 30:10
Well, and if you look at the consumer today, 10 years ago, people were barely using the iPhone and then think how much medical data is available today on the iPhone. Accelerating that another 10 years, that could be a major effect on how you deliver care couldn’t it?
Kevin Tabb 30:26
Absolutely and I think we will find ourselves surprised. As often as not, we have been wrong in prognosticating about the future. There will clearly be change. I’m not sure we know what the things that will have the biggest effect on. Nobody would have guessed that we would be able to roll out a safe and efficacious vaccine as quickly as we did. And I believe that that may have a larger effect on sort of how we do drug development and other vaccines than many other things that have happened and that may usher in an entirely new era of medicine more quickly than we imagined. But if you’d asked us two years ago, I highly doubt that anybody would have said, “That’s going to be an area where we’re really going to move forward quickly.”
Gary Bisbee 31:12
Yeah, inherently is what you’re saying is that cycle time used for vaccines, which was, people were saying it would take seven years or more and it took seven months, is that going to affect the cycle time a decision making at our health systems?
Kevin Tabb 31:28
I hope so. It’s going to affect the cycle time within health systems, it’s gonna affect the cycle time in drug development, it’s a whole host of things. I think, what we found acceptable, we no longer find acceptable in terms of, let’s take our time, but yeah. We need to do things in a safe, effective, data-driven fashion. There are also cases in this pandemic of throwing things at the wall, making statements about things that people might think might work but where there’s no science behind it, and I would strongly advocate our not doing that. But we need to move more quickly where there are data and science to back it up.
Gary Bisbee 32:09
Well, this whole flap over monoclonal antibodies sounds like a good example of what you’re talking about.
Kevin Tabb 32:15
Well, hydroxychloroquine is the best example. Monoclonal antibodies, I think is another example where there is not yet great evidence to suggest how effective it is. I think we have increasing evidence that it is relatively safe, but they’re not great evidence that suggests how effective it is. And given the limited resources and how intensive the work is to use monoclonal antibodies, I think there’s been reticence on the part of stretched providers to rush into a treatment that hasn’t been proven.
Gary Bisbee 32:44
Kevin, this has been a terrific interview. I’d like to wrap up with a few questions about leadership. And I’ve asked you this before but it warrants repeating. What do you think that the most important criteria for leadership in a crisis?
Kevin Tabb 32:59
Leadership, I think in many ways, is simple, although we tend to make it complicated. For me, it comes down to listen to your people, empower them to do good things, break down barriers where they exist, and get out of the way. I have said frequently, I’ll say it again, great ideas don’t actually come out of the corner office. They come from people who actually do the work. And our job as leaders is to listen and help bring those ideas to life. And that’s true in the day-to-day course of running a healthcare system, but it’s also true in the middle of a crisis. And so I think that’s something that doesn’t change and is just as important today and will be just as important tomorrow.
Gary Bisbee 33:51
Succinctly stated. This is a good place to land. Kevin, thanks so much for spending time with us this morning. Excellent interview.
Kevin Tabb 33:58
Great. Happy to do it. Thank you, Gary.
Gary Bisbee 34:01
Fireside Chat with Gary Bisbee is a Health Management Academy podcast produced by Think Medium. Please subscribe to Fireside Chat on Apple Podcasts or wherever you’re listening right now. Be sure to rate and review Fireside Chat so we can continue to explore key issues with innovative and dynamic healthcare leaders. In addition to subscribing and rating, we’ve found that podcasts are known through word of mouth and we appreciate your spreading the word to friends or those who might be interested. Fireside Chat is brought to you from our nation’s capital in Washington, DC where we explore the strategies of leading health systems through conversations with CEOs and other interesting leaders. For questions and suggestions about Fireside Chat contact me through our website firesidechatpodcast.com or firstname.lastname@example.org. Thanks for listening.