In this episode of Fireside Chat, welcome back James Hereford, President and CEO, Fairview, to discuss how the system has dealt with the COVID crisis and lessons learned in dealing with the surge. We also talked about changes in financing and delivery, and what the next generation of health system CEOs will look like in the future.
Fairview President and CEO James Hereford joined Fairview in 2016 bringing extensive experience in strategically guiding organizations, strengthening core operations, and bringing teams together to drive cultural change. Prior to joining Fairview, James served as chief operations officer at Stanford Health Care. Previous roles included chief operations officer at the Palo Alto Medical Foundation and a series of leadership roles with the Group Health Care Delivery System. Read more…
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James Hereford 0:03
What COVID has done is accelerated a lot of the forces of transformation that were already in play – affordability, ease of access, our ability to really be able to manage total cost of care, to be able to manage the spectrum in the continuum of care. Those were all present pre-COVID, but what happened with this pandemic and the stress that it’s put on systems is that those have all been accelerated, along with consumerism, I still think maybe the biggest driving force in many ways in our industry.
Gary Bisbee 0:35
That was James Hereford, president and CEO Fairview outlining the forces of transformation underway pre COVID and what the most significant fundamental change to the delivery system COVID will leave behind. I’m Gary Bisbee and this is Fireside Chat. Stay tuned for an in-depth conversation from the frontlines of the COVID battle. James reviewed the current status of COVID in Minneapolis/St. Paul and all of Minnesota, provided us an update on Fairview since our last discussion in April 2020 immediately before the first surge, dug into the changes in financing and delivery that are already underway instigated by COVID, and wrapped up with how the next generation of health system CEOs will look different than today’s. James references the network of nine health systems in Minnesota working together along with the Department of Health to contribute to an efficient process for testing and treating COVID patients and now turning to increasing vaccine distribution and administration. Let’s listen.
James Hereford 1:39
What we’ve been advocating for with the Department of Health, and I think we’re making good progress on this, is we have the infrastructure and the capabilities to greatly accelerate vaccination. We do this. This is what we’re here for. And I think we’re making progress on that. And I think that’ll allow us to be much more effective. And if you look at the states who have really done it well, West Virginia is a great case study, it’s exactly what they’ve done.
Gary Bisbee 2:05
James discussed his self-described obsession with creating economic alignment with payers to best spend the premium dollar to maximize the impact on health.
James Hereford 2:15
We need to get much better alignment, economic alignment between payers and providers. And I still am very desirous of having the kind of payer partnerships that allow us not simply to be at risk for our existing MLR, that’s a different version of the same game, but to really look at the premium overall and say, how do we best spend that premium to maximize the impact on health? That should be common ground we all could stand on.
Gary Bisbee 2:43
I’m delighted to welcome James Hereford to the microphone. Well, good morning, James, and welcome.
James Hereford 2:53
Good morning, Gary.
Gary Bisbee 2:54
We’re pleased to have you at the microphone for the second time, so thank you for queuing up again.
James Hereford 3:00
It’s always good to talk to you.
Gary Bisbee 3:02
Let’s start with where we’re at in terms of COVID and Fairview Minneapolis, Minnesota. When we last spoke it was late April and you were saying at that point that the first surge was four or five weeks away. So how did that work out? Did the surge hit late May, early June?
James Hereford 3:22
Yeah, it looks like I was fairly pressured at that point. Probably better to be lucky than good. But yeah, that’s exactly it. We saw our peak in late May, early June, really our first surge at that point. And we were working from a pretty extreme position of ignorance as we were trying to figure out what was the right clinical treatments, but also what were the right care processes.
Gary Bisbee 3:44
And at that time you weren’t doing any elective surgeries as I recall.
James Hereford 3:48
No, we were completely shut down at the state level in terms of surgeries. And I always go back and correct the idea of elective surgeries when we use that word because there are very few elective surgeries. Most of them are time-based and some can be delayed. But what we have seen since is some of the price that’s paid for delaying those surgeries. Yes, we could delay them, but if you’re having cancer surgery, cancer continues to progress until you have that surgery. It is a necessary intervention. So yeah, we can delay it, but it has clinical consequences. And so we were in that period. And then that instructed us a lot as we approached the next surge later in the year, how we were going to approach our surgical schedules.
Gary Bisbee 4:31
Are you back to full time now, surgical schedule?
James Hereford 4:35
Yes, we were really at full production in August and then we had a second surge and a much larger surge late November through a good portion of December.
Gary Bisbee 4:47
What about the patients? Have you had any issues with patients being reluctant to come in for surgery, concerned about COVID?
James Hereford 4:56
Well, there’s certainly I think there’s a level of reluctance, but at the same time, I’m proud of our system. I think we did a good job of both managing infection risk and our data would bear that out, but also communicating with our patients about how we were doing that, how we were going to keep them safe, why visitation rules had to change, how we were accommodating that through technology. While there was reluctance, I think people also understood what was the relative risk and the risk of delaying versus fairly low risk of acquiring COVID in a hospital. As it turns out, hospitals are one of the safest places if you’re trying to avoid COVID because of all the infection control measures that we’ve taken.
Gary Bisbee 5:36
How are the caregivers doing? They’ve been under pressure now for more or less a year. Is that having any effect on our caregivers?
James Hereford 5:46
Early on there were the “healthcare heroes” and everybody was paying attention to the healthcare heroes. And then as our society tends to do, we’re moving on to other things. And goodness knows there was plenty of things at the national level for us to pay attention to on any given day. And people were paying attention to those heroes, the free meals, media attention, got displaced by other things, but they were there day in and day out, caring for people and under incredibly difficult circumstances, and was having a personal impact on them. So yes, absolutely. I think the impact from burnout and the stress that has been caused related to COVID and then everything else that we’ve had to go through as a society, socially, economically, that healthcare workers have paid, in many ways, the largest price in that.
Gary Bisbee 6:37
Yeah, your colleague CEOs are all reporting that for sure. If you stand back from this, James, which is probably hard to do given the everyday nature of it. But if you stand back, what are the several lessons that you’ve learned from COVID?
James Hereford 6:53
It’s a great question. I mean, the most obvious ones are around e-health and use of technology and I think CEOs and all the systems can quote chapter and verse about, “We’ve done orders of magnitude more e-visits and in a period of months than we had in years.” And with that, I think we’ve changed our own patterns of care and we better understand how to integrate various modalities of technology into that care process. And we’ve changed the expectations of our patients. I think more fundamentally what COVID has done is accelerated a lot of the forces of transformation that were already in play – affordability, ease of access, our ability to really be able to manage total cost of care, to be able to manage the spectrum in the continuum of care. Those were all present pre-COVID, but what happened with this pandemic and the stress that it’s put on systems is that those have all been accelerated, along with consumerism, I still think maybe the biggest driving force in many ways in our industry. Because of COVID and because of other factors, but accelerated by COVID, I think consumerism has also been and continues to be it was there before, but I think is an even bigger driving force in our healthcare organizations. It’s gonna force transformation.
Gary Bisbee 8:11
Let’s move to vaccinations, a lot of people are concerned about that, of course, and distribution and supply, and so on. What role is Fairview playing in the whole vaccination process?
James Hereford 8:24
We’ve largely been focused on the 1A population of caregivers. So Fairview, we’ve got 32,000 or so employees. We’ve also been taking accountability for getting a lot of the adjacent clinical groups or employees who aren’t part of our system but didn’t have a system to go to in terms of their vaccinations. So we’ve largely worked through that. We have a little bit left to go. That allows us now to start to move into patient populations, which is good because it was a huge demand out there and a lot of fog about how to get vaccinated. I think the two biggest challenges, one is just it has not been clear from the federal level, what the supply is going to be. And, you know, you appreciate this from an operations perspective. If you don’t know the supply, it’s really hard to manage the demand and to be able to smooth that demand and effectively set yourself up for scheduling processes, etc. I think the second is and it goes to the relationship between what role the state and public health plays and the role that the systems can play. And what we’re advocating for, there are nine systems that make up the majority of the care in Minnesota. The nine CEOs get together, almost sounds like the mafia, doesn’t it? The nine CEOs get together on a weekly basis and what we’ve been advocating for with the Department of Health, and I think we’re making good progress on this is, we have the infrastructure and the capabilities to greatly accelerate vaccination. We do this. This is what we’re here for. And I think we’re making progress on that. And think that’ll allow us to be much more effective. And if you look at the states who have really done it well, West Virginia is a great case study, it’s exactly what they’ve done. They’ve been dependent on healthcare systems who have the infrastructure and capabilities to accelerate their ability to vaccinate the population, which benefits us all. There’s still a significant role for public health because not everybody is in one of the large healthcare systems. And some people aren’t proximate to any healthcare system. So there still is a role, and that’s what we’ve been working on is, how do we get crisp about our relative roles and how do they complement each other? So we’re not competing, either between the state and the healthcare systems or within the systems, dialing around looking for somebody who will vaccinate them. That’s just inefficient and wastes our resources that we can apply better in more effective ways.
Gary Bisbee 10:48
If I could follow up on that, if COVID has taught us anything or the pandemic has taught us anything, it’s that our public health infrastructure is not particularly well developed. And it does seem that the health systems have a lot of core capability there. Do you sense is there any pushback on the part of the public health agencies, not necessarily Minnesota, but just generally, is there any pushback on the part of the public health agencies to reaching out to the health systems and using them as part of the infrastructure?
James Hereford 11:23
I don’t think there’s any pushback. I think we’ve had an ongoing relationship with the governor and with the commissioner of health throughout this pandemic that’s been very, very constructive. I think what happens though, is especially under the pressure of a worldwide pandemic, role clarity becomes really important, right? And if you don’t have clear role clarity, we do this, you do that, this is how these complement each other, here’s how we adapt to shifting circumstances, which is, by necessity, requires a level of constant communication given how dynamic this has been. That’s why I think you can get crossways. Some of the things that we’ve been able to do with our department of health, I think, have been very innovative. We, as the large healthcare systems, put together, at the peak of the last surge when everybody was concerned about ICU beds, and especially if you’re a small rural hospital, how do you find an ICU bed and are you going to have to sit around and dial from one. We put together a central intake place, ML Fairview hosted that, we called it the C4 for that placement, but we worked in concert with the state to be able to establish that. They helped fund some of the extra resources it was going to take to do it. But we were able to then place critically ill patients into ICU beds across the state fairly efficiently, even when we were at the peak of demand. So I think there are plenty of those examples where we’ve came together well. I don’t know what post-pandemic, when it is or what it looks like. But I do think there’s a conversation that we need to have, whether it’s in the state of Minnesota or whether it’s much broader than that in terms of, what’s the role that, by necessity, we have to have an effective public health response. What does that look like? And what do they do? And how does that then relate to healthcare systems and what they have to do?
Gary Bisbee 13:10
You’re obviously closely aligned with the governor. Any sense of where the senators and representatives sit on this because it is a circumstance where there probably needs to be national leadership in this public health space. How do you view that, James?
James Hereford 13:26
I think, like so many things in our country right now, we’re in a pretty significant division where it’s hard to find common ground between the two sides. I have hope, hopefully not naive optimism that we’re going to be able to come through this period and find more of that common ground, knowing that there’s various points of view. Nobody has the lock on truth here. But I do think that the more that we can come together and talk about, what are the outcomes we’re trying to achieve and what role does government play in that and what role does the private sector play in that and how do those two relate to each other, the better off we’re going to be. I think Minnesota, like many states, has been a reflection of the broader body politic. And we’ve had a divided legislature so that’s also made it politically more interesting. But I do think, credit to Minnesota, all that being said, we’re a state that, at the end of the day, comes together, protects itself, protects its citizens, sees the greater good, so I have a lot of optimism about what we’re going to learn from this and where we’re going to land.
Gary Bisbee 14:29
Back to vaccinations for a moment. What information do you have on the declination rate or how many people of the caregivers are basically refusing to take the vaccine?
James Hereford 14:42
We’ve had relatively low declination rates – in the neighborhood of 5 to 10%. Now, what I don’t have as crisp a view on is, the people who have not been vaccinated, is that a declination by non participation or not or was it circumstances, just the logistics of getting in, couldn’t get scheduled, out on vacation, whatever. So we’re coming back and we’re cleaning that up. But at this point, I was really concerned because of what I was hearing from Los Angeles 30 to 50% declination rates, we haven’t seen that. So I’ll be able to give you final numbers here probably in the next week or so about how many passive declarations that we had, but at this point I’m feeling pretty good about where people are.
Gary Bisbee 15:26
That 5 to 10%, I’ve heard that from other health systems. There is the same point that you’re making is, you’re not sure how many people just haven’t gotten around to it or haven’t matched up with it, but it sounds like a relatively small percentage. Well, let’s move on to Fairview. Can you give us an update on Fairview, James, and where you stand now?
James Hereford 15:48
I think the work now is the same as it’s always been. Financially, COVID did us no favors. The good news is we went in with a strong balance sheet. We come out of it, at least 2020, with a slightly less strong balance sheet, but from that perspective we’re fine. We still need to do the things that we said were critical going into 2020. We need to lower our cost structure, which we’ve done a significant amount of work but not all the work that we had planned because of the pandemic. We unfortunately had to go through a series of layoffs in the fall, which are difficult, But I’m proud of our team, we laid off 900 people and we placed 600 of those. So it wasn’t so much a matter of we have too many people, but we’ve got the wrong people in the wrong place. And we’ve done a nice job, I think, of being able to get them to the right place and maintain that continuity. We’ve restructured our ambulatory system, which was largely a reflection of literally decades of small decisions and acquisitions. So now we’re well on our way to having a much more rational hub and spoke system in our primary care and our specialty care sites. It’s allowed us to be much more efficient and effective, I think, in how we address the continuum of care. We’re simultaneously changing some of our inpatient sites. One in particular, we’re converting into less of an inpatient setting and much more of a community hub for wellness and changing the role. At the same time, we’re making pretty significant investments in other of our inpatient facilities to make sure they’re upgraded. Little things like private rooms, which you fully appreciate how limiting semi-privates in a pandemic. So we’re making upgrades in procedural suites and having private rooms throughout the system. And then we’re working on, digital is going to be, as my chief digital officer likes to say, we’re all digital companies, whether we recognize it or not is the thing is, how do we become a much more effective digital company, both for our consumers and for our clinicians and the people who work for us, and making sure that digital is making jobs easier, not harder. We obviously have to react to now a much more mobile workforce, which was a tough transition, in some ways. It accelerated some of our technology infrastructure changes, but it also has given us interesting flexibility in terms of who we can employ and how we employ them, and frankly, where we employ them from. So there’s a lot of really nice things about where we’re at, where we’re going, and there’s a ton of work to do. And I’m still maybe a little overly indexed, some might say obsessed about, we need to get much better alignment, economic alignment between payers and providers. And I still am very desirous of having the kind of payer partnerships that allow us not simply to be at risk for our existing MLR, that’s a different version of the same game, but to really look at the premium overall and say, how do we best spend that premium to maximize the impact on health? That should be common ground we all could stand on. And it’s amazingly hard and not because necessarily a bad intent, but just the inherent complexity of self-employed versus government funders versus indemnity insurance and how that interacts and how you make that work pragmatically, it has a set of barriers. But I think that’s the key to us as an industry being able to more affect health outcomes as opposed to being good at providing care once people have some disease present.
Gary Bisbee 19:18
Totally agree. Some have called that the new middle, partnerships between insurers and providers. What’s your thought about moving down that path? Is it possible to do that in the private sector or is it going to take federal government leadership?
James Hereford 19:37
I’ll give you my frank answer. If we don’t do it from a, quote/unquote, “private sector perspective,” I think it’s going to be done to us by the federal government and I have been a student enough of other kinds of healthcare systems in other countries to know that is not a panacea that will suddenly fix all ills. I would much rather see us in the private sector come up with innovations and solutions to this and figure out that middle ground. Because if we could approximate what the systems like Kaiser and others have done, but not need 60 years and some unusual starting conditions, plus we don’t have 60 years to bring about the effect, between more traditional payers and providers, I think that gives us a pathway to being much more innovative to leveraging the natural advantages we have and to be able to make a convincing case at the federal level that we can do this. Now, we’re still gonna need federal help in terms of, how do we think about the ever-increasing portion of the dollar that pharma is taking? And I’m not sure we found good equilibrium there. I think that whether it’s med-tech, pharm, or infotech, those costs continue to drive a larger and larger portion of our overall supply costs. Labor is what it is, but those supply costs we have to be able to manage.
Gary Bisbee 21:04
Getting back to the new middle, do you think that the pandemic will encourage both the health systems and health plans to get together and find this new level of partnership?
James Hereford 21:18
No, frankly. I don’t think there’s anything about COVID, other than it disproportionally favored the plans from a financial perspective and was harmful to the providers. I think what it’s going to take are a few leaders who see the opportunity, are willing to take the risk to make the change, and then work their tails off to demonstrate the superior outcomes – financially, clinically, from a health perspective, dealing with health inequities – that’s what it’s going to take. We need some existence proofs here, outside of a lot of good PowerPoints, but not a lot of deliverable. My hope is that we’ll do it in Minnesota and Fairview will be at the heart of it.
Gary Bisbee 22:02
Yeah, let’s hope, but you’re right about the fact that we need some role models. Well, back to Fairview. Can you bring us up to speed on the M Health Fairview initiative? When we last met, that was relatively early, as I recall. How’s that working out?
James Hereford 22:19
It’s working out well. We still have work to do in terms of maturing this partnership, which is more complex, there’s no doubt about it in terms of how do you take essentially three separate organizations and work effectively together. One of the outcomes of a pandemic though is we demonstrated to ourselves a couple of things. One is, when we sit down and ignore the parochial barriers of the organizations and focus on how do we care for patients, we can be incredibly effective. The second thing is that we demonstrated the power of having an academic partner, an academic arm that creates a real learning health system. Because we went into COVID incredibly ignorant, as did everybody. We just didn’t know what this disease, how it was going to manifest itself, how it was presenting, how its transmitted, how to best care for patients. When we started we had Lombard, Italy; we had Wuhan, China; we had Seattle; we had New York, and all of those scared the bejeebers out of us, but we just didn’t know. What we’ve been able to do through systematic application of the science and the research and what the university can bring to us and that infrastructure to the application and immediate application, there was no like 14 years between bench to bedside, it was much more immediate. I think we can demonstrably show from our outcomes to how effective and how advantageous that was. So I think that was, in a way, our own existence proof that showed us what’s possible when we fully leverage these capabilities for the outcome, for the goal, which is taking better care of patients.
Gary Bisbee 23:59
Let’s move to some of the impacts of COVID. You spoke about telemedicine earlier and, of course, as you mentioned, everybody has their figures about the dramatic increase in telemedicine. But if I could ask the question in relation to what you’re talking about with the impact to the consumer, what is this forced use of telemedicine going to do over the next several years in giving the consumer more influence over the type of care they receive?
James Hereford 24:29
Well, I think it’s certainly lowered any barriers for consumers to feel comfortable about using telemedicine. It’s not the panacea. We’re not going to do surgical procedures via telemedicine anytime soon. But I do think the expectation of consumers for just what can be done effectively through other modes than coinciding a physician, a patient in an exam room so we can code a 99213, I think that’s fundamentally shifted. And both the opportunity and the risks, the opportunity is that we can deliver that, we know we can. The risk is a lot of other people, well-funded people, also see opportunities to disintermediate and deliver that value proposition to people. Now, they can’t provide the entire continuum of care. What happens when you need a specialty referral? Well, they’re going to be pretty silent about that. And I think, at the end of the day, that’s, I think, going to accelerate, as I said, that level of consumerism that’s going to impact healthcare significantly.
Gary Bisbee 25:32
Just to be clear on what you’re saying. So it sounds like we probably all thought telemedicine was primary care to begin with, but it sounds like it’s gone beyond that and you can use telemedicine for certain types of specialty care or post-surgery care, something like that. Is that true, James?
James Hereford 25:52
Certainly, for a number of things it applies across the continuum. We probably take out inpatient because if you’re in a hospital, you probably need to be in a hospital, especially these days. But almost everything else has been impacted by it. Here’s a simple but very practical example. So when we were at the height of our last surge, our observation, and the science would say, is a number of people who presented in the ED were getting admitted to the inpatient environment but didn’t need to be. And we knew why, we knew what the risk factors were. The problem is, we didn’t have an effective way to manage those patients if we sent them home so that we could manage the risk factors. Well enter telemedicine, so we use a product, the Health Loop is the product that we use, to be able to systematically manage those patients. So if somebody presents in the ED, the algorithms and the science would tell us, okay, look, there’s a very low likelihood they really need to be hospitalized, let’s send them home. But let’s just send them home and hope, let’s send them home with the technology that allows us to do ongoing surveillance and intervene if conditions change. So that’s a great example of, that’s not primary care, it’s not inpatient care, but it impacts inpatient care. And we had literally dozens, if not hundreds of those kinds of examples, where we can use technology to accelerate and change the nature of the entire continuum of the care process.
Gary Bisbee 27:17
Turning to the organization of healthcare, you mentioned, you have nine health systems in Minnesota that are working together which brings up the idea of a regional health network. And you could think about that within a state perhaps sharing information and coordinating and so on, or you could think about it across states as a matter of ownership, actually. Do you think that there will be more regional health networks developing, that would be large health systems in certain regions or multiple states, and they do it on an ownership basis?
James Hereford 27:56
Most likely, yes. I think we’re going to see an increased level of M&A activity, although we’ll see what the federal regulatory environment is for that. And, frankly, the history of M&A activity, we can’t point to a significant decrease in costs due to that. In fact, everything that you read would point in the opposite direction. So we’re also gonna have to demonstrate why this is going to be good for consumers. I think the more interesting to me approach, and not that M&A may be a great example at some point of how systems come together, but healthcare, for the most part, tends to be fairly local, with quaternary medicine being the exception, and even tertiary, relatively small region, it tends to be a local endeavor. But think about the Medicaid programs. For the most part, all of the healthcare systems are participating in Medicaid. We don’t have great data; we aren’t affecting the Medicaid population in a way that’s improving health equity, that’s affecting the health of the population, because the interventions there to get upstream are very different, right? You have to deal with social risks. None of us are getting rich on Medicaid, quite the contrary. How do we come together and manage this population much more effectively, share data, share risks, share accountability, and start there, because then we could actually show clinical outcomes, we could show financial outcomes, maybe even get the reimbursement focused in the right places at the right times, to have a better ability to do that. That, to me, is the other aspect of it rather than full M&A, let’s just wait to see who gobbles up whom and who the big fish is at the end of the day. There’ll be that, there’s no doubt about it, and weakened health systems, I think, will see more of that. But I’m not sure that’s the only path to what you’re talking about.
Gary Bisbee 29:42
Let’s turn to leadership. Thinking about leadership, and I’m thinking about the CEOs role, do you think that the next generation of CEOs, the expectations for their performance or what characteristics they might have, do you think that will change at all due to COVID?
James Hereford 30:00
I don’t know how it can’t be shaped by it. I think it would be akin to asking veterans of World War II, “Gee, did that experience change your view of how you looked at the world?” I can’t imagine this is not going to significantly affect how future healthcare leaders and CEOs look at their world, because they went through this experience. God hope we don’t ever have to go through it again, but you gotta be careful who you listen to. If you listen to the epidemiologists or the infectious disease doctors, they would say that we’re guaranteed to do so. But I do think it’s going to influence and I think in positive ways. Because what’s been clear to me is, there is no form of the individual, I’m the smartest guy in the room approach to leadership in this environment that can work. You just can’t be – too many more smart people, you have to move too fast, you’ve got to create good teams, you’ve got to create an environment where they can make decisions and affect those decisions quickly. You’ve got to be able to be facile with technology and understand its impact both on the social and the technical side. It’ll change who we even think about as potential leaders. And then the thing we haven’t really touched on is the level of social unrest. And I think that too, simultaneous coincident to the pandemic is also going to change the way that we think about what is leadership and who are our future leaders?
Gary Bisbee 31:23
Carrying that thought to your board of directors, do you think that the expectations for the board by the community, let’s say, building on the social unrest issue, do you think that’s going to change?
James Hereford 31:34
Well, I think it has. I think our board, it was always visible, but it wasn’t a front-burner item in the way that it is now. I think it’s affected our agendas, it’s affected our recruiting strategies, it’s affected the conversations that we’re having at the board level. So yeah, I think absolutely, you’d have to have your head in the sand if you did. Our board definitely doesn’t have their head in the sand.
Gary Bisbee 31:58
Going through what you’ve gone through in the last year or so, what do you think are the characteristics of a leader in a crisis that stand out to you?
James Hereford 32:08
I think, obviously, a certain level of equanimity. There were so many unexpected, unusual events happening on a continual basis that there was a certain level of calm that you had to bring to this emotional intelligence, etc. I think that was clear. I think, as I said, the ability to create effective teams and trust those teams and work with those teams is absolutely crucial. I’m just so proud of what our teams did and how they came together. And I think creating an environment where teams are able to do that and feel empowered and understand where the guardrails are, and for leaders to be able to effectively communicate the guardrails and effectively communicate and work within the decision making processes that are matched to the tempo of the need. Those are absolutely crucial. I think the other part that is challenging is, especially at a time of such great urgency as a pandemic is, how do you continue to pick your head up once in a while and see the bigger picture? Because it’s very easy to get pulled down into the day to day, which is crucial and at the same time, there is a bigger picture out there. So how do you balance that near/far vision that has always been the case, I think, for senior leaders and for CEOs, but then became even more crucial during this pandemic.
Gary Bisbee 33:31
James, it’s been a terrific interview. We very much appreciate your time. Keep up the great work at Fairview.
James Hereford 33:37
Gary, it’s always a pleasure. Thank you so much.
Gary Bisbee 33:41
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