Best  Practices  in  Achieving  Physician  Engagement    

[Female  Speaker]  Summit  33  so  you  can  participate  in  the  poll  questions  and  the  applause  as  you  probably  all  know  by  now.  You've  probably  been  doing  this  many  times.  Feel  free  to  submit  questions.  We'll  vote  on  those  questions  and  of  course  you  get  points  for  all  of  that.  And  of  course  you  have  your  "Lessons  Learned"  in  front  that  you  can  make  notes  on  and  document  your  "One  Thing  That  You  Might  Want  to  Do  Differently"  as  a  result  of  this  panel.    We  have  our  analysts  this  afternoon  that  are  helping  us  -­‐-­‐  is  Jeff,  Cy,  Lexie,  and  Erin  are  over  there   who'll   be   doing   some   of   the   audience   analytics   and   questions   for   us,   the   poll  questions.    Great!  Are  you  ready  for  our  session  this  afternoon?  First  of  all  we  have  a  first  poll  question  there  if  somebody  could  put  that  up  there.  Next  one.  Do  you  want  to  go  ahead  and  do  that?                        

   Poll  Question  Number  1  [01:02]    [Male  Speaker]  Yes.  We're   going   to   do   a   couple   of   poll   questions   here.   So   number   one,   who   should   be  leading   the   quality   improvement   charge?   A-­‐   physicians,   B-­‐administrators,   C-­‐the  government?  We'll   give   you  a   few   seconds   to   respond   to   that   and   just   as   a   reminder   it's  session  33  to  find  in  your  app.    We’ll   look   at   the   responses.   Majority   85%   are   physicians   should   be   leading   the   quality  improvement  charge.                            

 

 Best  Practices  in  Achieving  Physician  Engagement  [01:55]    [Female  Speaker]  Great.  Well,   that  makes   this   session   all   the  more   valuable.   I'd   like   to   introduce  Dr.   Bryan  Oshiro  who's  the  Chief  Medical  Officer  at  Health  Catalyst  to  facilitate  our  panel  today.  Thank  you  very  much.    [Bryan  Oshiro]  Thanks   for  coming,  everybody.   Just  a  show  of  hands,  who  here   is  a  physician?  Okay.  Who  here  is  a  nurse?  Who  here  is  an  administrator  of  some  sort?  Okay.  All  right.  I  was  just  joking  with  Angie  over  there  that  we're  going  to  gang  up  on  her  because  there’s  three  physicians  up  here  and  we're  going  to  ask  all  these  questions.    Can  you  pull  up  the  first  slide  while  we...I  just  want  to  introduce  John.  John  is  from  Kaiser.  You  might  have  heard  of  Kaiser  organization.  It’s  a  little  hospital  system  somewhere  in  the  west.  I  don’t  know  exactly,  but  Chief  Medical  Officer  for  the  Colorado  system.      Sorry,  I  have  to  stand  in  front  of  the  podium  otherwise  you  couldn’t  see  me.  I  tried  walking  over   here   one   time   and   they   thought   that   God   was   speaking   because   they   couldn’t   see  anybody.  From  Mission  Health,  we  have  Angie  and  then  Jay  is  from  a  hospital  that’s  a  little  bit  smaller  than  Kaiser,  Thibodaux.  How  many  beds  are  there  in  Thibodaux?    [Jay  Fakier]  

180.    [Bryan  Oshiro]  180  beds    [Jay  Fakier]  It  varies.    [Bryan  Oshiro]  It  varies?    [Jay  Fakier]  If  needed,  it  varies  a  little  bit,  10  or  20  here.  We  confine  things  to  the  closet  if  we  need  to.    [Bryan  Oshiro]  Okay.   In  any  case,  over  the  past  few  years,  my  generation  of  physicians  of  over  50  and  so  forth,  a   lot  of  them  have  actually  changed  their   jobs  because  they’re  really  kind  of  getting  burned  out  and  so   forth.  This  always  comes  up.  How  can  we  be  more  engaged  or  on   the  other  hand,  for  leadership,  is  how  can  I  get  my  physicians  engaged?      This   is   a   national   survey   that   was   done,   a   Physician  Wellness   Survey   that   was   done   and  looked  over  a  three-­‐year  period  of  time.  I  think  this  survey  was  completed  in  2013  or  2014.  It’s  in  a  Likert  Scale  of  one  to  ten,  ten  being  really  engaged,  one  being  not  so  much.      You  can  see  over  here  that  it  goes  all  over  the  place,  but  even  at  the  best,  nine,  ten,  even  eight,  you  have  about  a  quarter  that   feel   like  they’re   fully  engaged  or  really  engaged.  The  rest  of  them  are  sort  of  middling  or  not  so  much  engaged.  Can  you  get  to  the  next  slide?  Oh,  I  have  the  next…never  mind.    These  are   the  15  elements  of  physician  engagement   that   they   talked  about   in   the   survey  and  so  forth.  This  is  in  order  of  what  they  felt  that  was  important  to  them.  Respect  for  my  competency  and  skills,  that’s  what  we  do  as  physicians.  We  want  to  be  respected  for  what  we  do  is  taking  care  of  patients.      On  the  other  hand,  on  the  lowest  scale  there  is  participating  in  broader  organizational  goals  and   strategies.  What   that   means   to   me   is   that   if   we   want   to   get   physicians   engaged   in  whatever  the  organization  wants  to  do  it’s  not  like,  “Hey,  we  have  this  vision.  We  want  you  to  come  on  board.  We’re  going  to  travel  this  road  together.  If  you  don’t  have  all  these  other  things  that  are  really  near  and  dear  to  physicians  already  there…”      How  many,  just  a  show  of  hands,  would  agree  with  looking  at  this  that  that  is  sort  of  what  your  experience  has  been?  Okay.  How  about  you  don’t  agree  with  this  at  all?  Okay.  Maybe  that’s  it.    Going  off   to   the  questions  here,  why  don’t  we   start   off  with   you,   John  and   stuff   and   say  what  do  you  see  as  some  of  the  barriers  in  your  experience  for  position  engagement?    

 [John  A.  Merenich]  I   think   of   our   physicians   are   hired   with   the   idea   that   they’re   going   to   be   team   players.  They’re   going   to   be   the   primary   patient   advocates.  We  want   them   to   be  more   than   just  technicians.  We  want  them  to  understand  the  strategy  and  more  than  understand,  actually  design  the  strategy  and  be  at  the  table  and  be  part  of  that  long-­‐term  view.  We  look  for  team  players,  people  that  are  going  to  participate.      One  thing  that  just  struck  me  up  there  in  terms  of  wanting  to  respect  competency  and  skills  is   just   challenge  a   little  bit   increasingly   for   the  doctors   to,   and   I   think   this   is   a  positive   in  most  cases  is  to  really  get  away  from  the  empiric,  to  rely  on  their  team  members,  train  with  their  team  members  and  play  that  kind  of  chief  facilitator  and  negotiator  role  and  be  that  primary  liaison…the  go-­‐to  person,  but  then  to  constantly  endeavor  to  innovate  and  disrupt  and  to  things  that  they  want  to  be  more  competent  on.  We  tell  primary  care  doctors  to  be  specialists.    That’s  the  kind  of  thing  that  we  were  trying  to  invoke.  To  get  them  part  of  not  just  feel  like  you’re  okay  with   this,  but  actually  help  derive   the   strategy  and  help  derive   the  outcomes  and  physician  leadership  is  key  in  our  organization.    [Bryan  Oshiro]  It  sounds  like  for  your  organization,  you’ve  been  working  on  this  for  a  while.  You’ve  kind  of  developed  this  and  it’s  evolved  over  time,  it  sounds  like.  Right?    [John  A.  Merenich]  That’s  correct.    [Bryan  Oshiro]  How   about,   Angie?   At   your   institution,   do   you   think   that   there’s   an   issue  with   physician  engagement?  Do  you  think  that  most  of  the  physicians  are  engaged?  Tell  us  a  little  bit  more  about  your  model  because   they  have  a  physicians’  group,  a  division.  How  does   it  work  at  your  institution?    [Angela  Wills]  Is  this  working?  It’s  on.  At  Mission,  we’re  an  ever-­‐changing  system,  if  you  will.  Over  the  last  five  years  we’ve  grown   immensely.  We’ve  grown   from  about  100  employed  physicians   to  over   600   employed   physicians   if   you   include   our   practice   service   agreement   groups.  We  now  have  five  hospitals   in  our  system  and  we  now  have  an  MHP,  Mission  Health  Partners  which  is  our  version  of  Medicare  Shared  Savings  Program.    The  culture  is  ever  shifting  and  alignment  with  key  strategies  is  crucial  in  order  for  us  to  be  successful.  We’ve  spent  a  lot  of  time  in  the  last  five  years  figuring  out  what  does  our  model  look   like,   how  do  we  engage  physicians,   how  do  we  have  physicians  driving   the   strategy,  leading  the  strategy,  really  helping  us  to  shape  and  form  who  Mission  is  and  how  we’ll  play  in  western  North  Carolina.    

The  partnership   is  so   important.   I  think  that  there’s  a  mutual  appreciation  of  the  different  skills   that   we   bring   to   the   table.   In   fact,   we’re   having   an   interesting   conversation   about  finance  the  other  day  and  my  physician  partner  I  was  talking  about  the  rolling  forecasting,  looked  at  our  finance  people  and  he  said,  “Is  what  she’s  saying  right?”  He  looked  at  me  and  he  kind  of  laughed,  but  he  said,  “You  know  I  don’t  know  that  stuff.”  I  said,  “I  know  but  I  also  don’t  know  what  you  know.”    It   is   the  partnership,   it   truly   is   the  partnership,  but  having  physicians  engaged  where  only  physicians   can   be   engaged   and   where   they’re   passionate   is   in   the   clinical   care   and   the  outcomes   of   the   patients.   If   you   engage   them   in   those   ways,   you’ll   find   that   the  partnerships  are  pretty  fabulous.    [Bryan  Oshiro]  What  percentage  do  you  think  of  the  physicians  are  really  fully  engaged  with  what  you  guys  are  doing?    [Angela  Wills]  20.    [Bryan  Oshiro]  20  percent.  Jay,  how  about  at  your  hospital?  What  do  see?    [Jay  Fakier]  Well,   first  of  all   it’s  very  humbling  to  sit  up  here  with  people  of  these  credentials.  Coming  from  a  small  hospital,  I  kind  of  start  this  with  anything.  Every  time  I  start  talking  to  anyone,  with  my  wife,  my  children,  people  in  the  audience,  I  always  tell  them  that  the  key  to  being  satisfied  with  all  performance  I’m  about  to  give   is  to   lower  your  expectations  which  we’re  about  to  get.  Start  off  there  and  everything  will  be  great.    [Bryan  Oshiro]  Match  your  voice?    [Jay  Fakier]  Yes.  Probably  one  of  the  barriers  that  we  saw  in  our  hospital,  of  a  small  hospital  was  past  experience  with   things   like   this   in  administration.  Whether  or  not   it  was   true   that  people  perceive  that  the  administration  was  not  wanting  the  right  direction  when  they  tried  to  get  doctors   involved   or   whether   it   was   actually   happening   doesn’t   matter.   It’s   what   they  perceived.      You   had   to   kind   of   divide   doctors   into   three   categories   in   which   you   had   your   younger  doctors  being  there  less  than  ten  years  that  were  easy  to  get  on  board.  They  came  through  a  residency  program  in  a  time  of  medicine  when  it  was  very  dynamic  and  change  they  could  easily  accept.      Then  you  have  the  doctor  that’s  been  there  for  25  to  30  years  maybe  with  five  years  left  in  his   career.   He   had   a   lot   of   experience  with   prior   things   like   this   and  may   not   have   been  physician-­‐led  that  were  very,  very  skeptical  of  the  whole  thing  and  maybe  rightfully  so.  You  

had  to  look  at  those  physicians  and  maybe  that’s  not  where  you  needed  to  put  a  lot  of  your  time   because   if   they   didn’t   come   along   you   had   five   years.   As   long   as   they   were   good  doctors  but  maybe  not  cutting-­‐edge  on  some  projects,  you  just  let  them  kind  of  watch  from  the  side.      You  have  that  doctor  that’s  been  there  ten  years  or  15  with  15  years  left  and  that’s  where  you   put   your   effort   forth   and   showing   them   that   this   is   going   to   be   physician-­‐led.   That’s  extremely  important  to  them.    As  far  as  that  question  goes  that  you  had  earlier  as  far  as  should  be  physician-­‐led,  should  be  administration,  I  don’t  think  it  should  be  that  basely  divided.  I  think  it  has  to  be  physician-­‐led   but   it   also   has   to   be,   on   the   administration   side,   led   as   well.   You   need   both   people  working   together  and   then  engagement   is   an  opportunity   to  get  doctors   to   communicate  better  with  the  administration.  It’s  the  only  way  we’re  going  to  move  forward.    At  first,  I  didn’t  want  to  be  involved  with  the  administrative  side.  I  didn’t  want  to  be  involved  with  the  money  of  medicine,  the  evil  side.  I  want  to  take  care  of  people.  I  want  to  go  home.  I  want  to  come  back  to  work  and  take  care  of  people.  As  you  get  going  forward  you  have  to  be   involved   in   that   side.   If   you’re   one   of   those   doctors   that   complains   about   the  administration  all  the  time  and  you  don’t  get  involved,  shame  on  you.    As  far  as  full  engagement,  I’m  not  exactly  sure  necessarily  where  we  have  full  engagement  yet   as   far   as   numbers   of   doctors.   I   think   full   engagement,   how   do   you   define   the   word  “full?”  Does  it  mean  that  all  150  of  your  doctors  are  engaged?  Or  does  it  mean  that  critical  doctors   are   fully   engaged?   I   think   it’s   more   important   to   have   the   critical   doctors   fully  engaged,  fully  passionate  than  have  all  150  on  board.    [Bryan  Oshiro]  Okay.  Any  comments  from  the  audience  on  that  at  all?  Okay.  What  about  that  comment?  There’s   two   things   on   there   that   kind   of   struck  me.  On   a   larger   system   like   both   of   your  systems,  you’re  going  to  have  a  broader  spectrum  of  age  groups.  Yours  maybe  not  so  much  and  maybe  you  can  wait  it  out  and  it’s  not  going  to  be  critical  for  your  place.      John,  what  do  you   think  about   that?  When  you  have   these  doctors   that  have  been   there  and  they’re  62  years  old,   they’re  getting  up  there  to  where  that  retirement  age   is  coming  up.  Do  you  kind  of  say,  “Well,  we’ll  just  kind  of  leave  them  there?”    [John  A.  Merenich]  There’s   a   matrix   that   we   sometimes   use   about   very   clinically   competent   people.   We  challenge  people  that  aren’t  clinically  competent  and  more  or  less  force  them  to  change  or  to   find   other   employ.   We’re   very   careful   about   how   people   are   brought   on.   That’s   the  competent  phase  and  there’s  not  very  many  incompetent  doctors  in  our  system.  It’s  a  very  rigorous  selection  process.    I’ve  been  with  the  group  now  20  years  so   I  guess   I’m  on  that  side  now  of   I  was  employed  and  I  felt  very  engaged.  I’m  one  of  the  older  doctors  at  the  KP  that  I  work  at.  There’s  not  a  lot  of  people  that  are  in  the  20-­‐,  25-­‐year  range.  The  fact  that  they’re  there  after  20,  25  years  

kind   of   says   a   lot   about   them.   They’re  mostly   engaged.   They’re   somewhat   skeptical   and  they’re  maybe  a  little  bit  more  cautious  in  terms  of  the  new  things,  jumping  on  board.    For  us,  it’s  kind  of  like  that  category  of  folks.  What  we  do  is  try  to  find  those  that  are  very  competent  and  very  engaged  and  really  focus  in  on  them  and  have  them  deal  with  the  rest  of   their   colleagues.   I   think   that’s  one  of   the  key   things   for  us   is   to   let  engaged  physicians  lead  by  example  and  actually  be  the  directors  and   let  doctors  try  to   influence  doctors.   It’s  been  very  successful.    Then   for   those  occasional   folks   that  are  not   very  motivated,   just   the  old   codgers  and  not  very   competent   and   they   just   don’t   keep   up,   we   let   our   quality   people   deal   with   those.  There’s  not  very  many  of  them.    [Bryan  Oshiro]  What  have  you  found,  Angie  in  your  institution  as  far  as  man,  these  things  really,  really  have  been  homeruns  for  us  to  get  physicians  engaged.  Have  you  had  any  of  those  techniques  that  you  can  share  with  the  audience?    [Angela  Wills]  I   think  a   lot  about   relationships.   I   look   through   that   list   and   I   see   respect  and   trust.   I   see  appreciation  for  my  competencies.  I  see  respect  for  my  work  and  life  balance.  A  lot  of  it  is  about   relationships.   A   lot   of   those   relationships   come   peer-­‐to-­‐peer.   A   lot   of   those  relationships   come   from   time   and   trust   and   building   friendships   and   going   through   good  times  and  bad  times  and  crucial  conversations.    I  don’t  see  the  age  as  a  key  indicator.  I  see  vision.  I  see  alignment.  I  see  trust.  I  see  passion.  I  see  respect.  Those  are  really  the  things  that  when  we  look  for  who  our  potential  leaders  are,  those  are  the  things  we  look  for  and  then  we  engage.  It’s  about  mutual  interest  in  common  goals.    [Bryan  Oshiro]  Just  another  question  for  you  since  you’re  the  only  administrator’s  side  on  this…    [Angela  Wills]  Friend  or  foe.  Friend  or  foe.    [Bryan  Oshiro]  Let’s   say   that   there’s   a   physician   there.   There’s   a   key   physician   at   a   key   service   line,  cardiovascular.  Maybe   he’s   you’re   best   thoracic   surgeon   or  maybe   he’s   your   best   neuro-­‐muscular   surgeon   and   he   just  was   burned   before   and   just   is   very  wary.   How   do   you   get  people  like  that  involved?  Because  he’s  not  one  of  those  “I  have  this  vision,”  he’s  doing  fine  all  on  his  own.    [Angela  Wills]  Interestingly  enough,  a  little  bit  about  my  history;  I  have  26  years  with  Mayo,  with  a  group  of  all-­‐employed  providers  then  I  flipped.  I  decided  it  was  time  to  go  to  the  dark  side,  which  

was  anything  non-­‐Mayo.  The  culture  when  you  go  from  organization  to  organization  is  very,  very  different.      The  physician  culture  is  very,  very  different.  You  find  amazing  clinicians,  and  it’s  come  up  in  several  of  the  conversations  over  the   last  couple  of  days  who  “The  way   I’ve  done   it   is   the  best  way  and  my  outcomes  are  great  even   if   I  don’t  appreciate  what  my  outcomes   really  are.”      For   us,   it’s   been   really   powerful   to   be   a   data-­‐driven  organization,   to   look   at   variations   in  care,   to   appreciate   those  who   have   really,   really   phenomenal   outcomes   to   look   for   peer  kind  of  coaching  and  conversations.  Oftentimes  the  attitudes  change  and  I  liked  the  grieving  process  about  your  data  because  you  see  it  again  and  again.  I  think  if  you  can  agree  that  the  data  is  valid,  that  the  data  is  sound,  that  the  best  practice  really  is  the  best  practice  and  then  you  start  talking  about  outcomes,  people  get  there.    [Bryan  Oshiro]  Yes.    [Angela  Wills]  All  people  get  there.    [Bryan  Oshiro]  Okay.  It  sounds  like  instead  of  maybe  trying  to  convince  somebody  by  having  this  argument  with  them…    [Angela  Wills]  We  don’t  argue    [Bryan  Oshiro]  It’s   let   the   data   speak   for   itself   and   maybe   they’ll   come   around   that   way.   Jay,   you  mentioned   that,   “Geez,   I’m   just  a   radiologist,”  very  humble  statement   from  you  earlier   in  our  conversations  and  so  forth,  I’m  just  interested.  How  did  the  administration  get  you  on  board  and  say,  “Yes,  I  really  want  to  do  this.  I  think  this  is  the  right  thing  to  do?”    [Jay  Fakier]  First  of  all,  I  want  to  echo  what  John  said  about  the  comment  as  far  as  the  physician  that  has  been  there  25  to  30  years  that  you  may  not  get  on  board.  It’s  not  necessarily  because  of  the  skill  level  or  the  thing,  I  highly  respect  those  and  look  up  to  a  lot  of  those  and  getting  those  onboard  are  very  important  and  also  your  opinion  that  there  can  be  fabulous  leaders  in  all  ranges  through  that.    Going  back  to  your  actual  question,  Ron,   is   that   first  of  all   in  choosing  the  physicians   that  were  going  to  lead  the  physicians,  it’s  very  important  and  not  to  toot  my  own  horn  because  I   was   selected.   I   didn’t   select   myself.   You   have   to   find   somebody   that   is   trusted   by   the  medical   staff,   somebody   that   themselves   is   righteous,   somebody   that  will   talk   to  another  physician   and   that   physician   can   believe   that   individual   and   know   that   it’s   not   a   whole  

bunch   of   smoke   and  mirrors  while   they’re   drinking   the   Kool-­‐Aid   on   the   second   floor   and  they’re  trying  to  get  everybody  else  involved.    You  have  to  believe  in  yourself  and  you  have  to  believe  that  when  you  go  and  if  you  have  to  go   to   battle   with   them,   you   won’t   force   anybody   with   violence   to   get   involved   because  that’s  not  going  to  be  a  passionate  person  about  your  cause.  That’s  one  thing.    Secondly,   as   a   radiologist   in   a   service-­‐oriented   specialty   I   spend   most   of   my   day   not  necessarily  making  a  patient  happy  but  spend  most  of  my  day  making  other  doctors  happy  which   is   kind   of   a   key   thing.   You   learn   their   personalities.   You   learn   their   personality  disorders.      That  way  when   you  have   to   go   speak  with   a   certain  physician   to   get   them  on  board   you  know  how  to  talk  with  that   individual  because  you’ve  had  that  same  conversation   in  your  office  whether   it’s   been  a   very  mellow   conversation,   a  patting  on   the  back  or   it’s   been  a  conversation  of  rage  and  frustration  but  that’s  what  they  respect  from  each  other.  That  did  kind  of  give  me  a  little  bit  of  advantage  to  know  kind  of  everybody  and  where  they  sit  and  where  they  play  in  the  years  I’ve  been  there.    For  instance,  on  the  first  medical  staff  meeting  that  we  had  where  we  kind  of  announced  we  we’re  going  to  do  this  care  transformation  process,  I  know  exactly  who  to  sit  next  to.  I  knew  who  was  going  to  be  the  first  person  to  stand  up  and  say,  “Nay.”  That  has  kind  of  helped  me  in  moving  forward  with  this.    [Bryan  Oshiro]  Okay.  For  all  of  you  aspiring  physician  leaders,  administrative  leaders,  instead  of  getting  an  MBA,  you  need  a  degree  in  Psychology.    [Jay  Fakier]  That  is  no  doubt  about  it.    [Bryan  Oshiro]  John,  once  you  set  up  this  system  and  say,  “We’re  getting  quality  folks  in  and  we  have  a  nice  system  that  they  can  come  into.”  I’m  sure  there  are  people  that  are  still  not  really  engaged  in  your  system.    [John  A.  Merenich]  Yes.  A  lot  of  this  is  what  does  it  mean  to  be  engaged?  There  are  a  lot  of  physicians  who  are  extremely   competent   and   they   like   to   come   in   at   4:00   in   the  morning   and  work   till   8:00.  That’s   what   they   do.   You   take   advantage   of   that.   That’s   engagement.   They   respond   to  challenges  for  the  organization.      When  we  say  engagement,  what  behavior  are  you  trying  to  change?  We  often  ask  patients  or   doctors   to   do   something   differently   and   they’re   not   responding   to   do   something  differently  and  they  were  used  physician-­‐to-­‐physician   in   the  data,   in  analytics  because  we  call   on   this   very   good   data   and   peak   curiosity.   We   ask   people   to   maybe   change   their  behavior  in  that  regard.  It’s  that  kind  of  aspect  of  engagement.    

 I’d   say   it’s   half   of   our   physicians   that   they’re   there.   They   will   try   new   things   and   they  respond  to  good  quality  data  and  well-­‐represented  data  and  especially  when  it’s  presented  by  physicians  where  there’s  a  good  reason  to  do  the  change.  Then  there’s  the  people  that  you’re  asking  to  engage  and  becoming  involved  in  strategy,  go  to  the  content  meetings,  set  up  the  metrics,  deal  with  the  health  plan  employees,  and  all  that  kind  of  stuff.      I’m  just  trying  to  distinguish  the  two  because  that’s  not  for  everybody.  I  think  it’s  just  to  find  your   position   in   the   team.   I’m   having   a   difficult   time   answering   generically   to   the  engagement  question.  I  presume  that  there  are  things  that  when  you  have  something  that  needs   to  be   changed  either   to  do  or   stop  doing   something   and   it’s   not  happening,   that’s  where  we  have…    [Bryan  Oshiro]  Engagement  is  interesting.  Another  way  to  look  at  it  is  maybe  to  say,  “How  satisfied  am  I  as  a  physician  working  in  your  organization?  Am  I  happy  to  be  involved  with  projects  and  do  I  go   along   with   the   company   philosophy?”   In   that   vein,   do   you   do   any   internal   physician  satisfaction  surveys  and  what  do  they  show?    [John  A.  Merenich]  Are  you  kidding?  Of  course.  We  measure  everything.  We  have  internal  patient  satisfaction.  We  have  doctor’s  satisfaction  with  other  doctors,  which  went  over  variably.  I  think  it  didn’t  work  very  well  because  it  was  anonymous.  I  thought  it  was  crazy.  We  shouldn’t  have  done  that.  If  you  have  something  to  say,  you  should  say  it  face-­‐to-­‐face  so  we  abandoned  that.  We  have  metrics  for  people  that  have  panels,  how  these  stack  up  against  their  peers.      By  the  way,  if  you  have  multiple  metrics,  you  usually  find  that  doctors  are  really  good  in  this  one  and  middle-­‐of-­‐the-­‐pack  on  this  one  and  maybe  lower  on  the  other  one.  It’s  never  best  practices.  We  always  say  better  practices  so  that  even  the  best  can  always  get  better  and  they  learn  from  each  other.  We’ve  always  used  data  and  these  analytics  as  a  carrot,  never  a  stick.    Another   thing   that  we’ve  also  done   is   try   to   roll   up   so   that   the  doctors   are  part  of  pods,  groups.   It’s  small  enough  to  be  change.  “Hey,   I  want  you  to  do  this  a   little  bit  differently.”  It’s  not  down  to  the  personal  level  where  it  gets  personal.  You  have  teams  of  five,  seven,  ten  that  kind  of  act  together  and  you  evaluate  those  kind  of  team  basis.  That  generally  works  for  changing  behaviors.    [Bryan  Oshiro]  It  kind  of  goes  along  with  what  Jim  Collins  said  yesterday.  I’m  not  sure  if  you  were  here  for  that.  He  said,  “It’s  all  about  leadership  at  the  unit  level.”    [John  A.  Merenich]  Yes,  that’s  right.    [Bryan  Oshiro]  

It’s  all  about,  “I’m  doing  it  for  my  buddies  kind  of  thing  in  battle.”  Angie,  anything  to  add  as  far   as   from   your   perspective   do   you   guys   have   any   programs   like   that   to   kind   of   survey  periodically  and  address  that  specifically?    [Angela  Wills]  A  couple  of  things.  One  thing  that  we’ve  been  working  on  and  it’s  physician-­‐led,  it’s  led  by  our  Chief  Medical  Officer,  is  coming  up  with  our  agreed  upon  guiding  principles.  Those  have  to   do   with   the   way   that   we   engage   with   one   another,   the   way   that   we   align   as   an  organization,  what  are  really,  truly  what  our  mission  and  goals  are.  Those  guiding  principles  will   be   signed   off   by   all   caregivers   whether   they   be   administrative,   whether   they   be  physician,  whether  they  be  nursing.  It’s  a  nice  way  for  us  to  say  we’re  all  in  the  same  boat.    Another  thing  that  we’ve  been  doing  and  it  doesn’t  answer  your  question  directly  and  I’ll  get  to  that  is  that  we’ve  aligned  all  of  our  incentives.  I  think  it’s  been  really  shocking  actually  to  many  of  our  provider  groups  to  appreciate  that  the  administrators  have  a  fair  chunk  of  their  salary   at   risk   for   the   same   outcome   metrics   that   they   have   even   though   we’re   non-­‐clinicians.   That’s   our   commitment   to   them   to   remove   the   system   barriers   to   help   make  them  successful.    Once  they  appreciate  that  we’re  all  in  it  and  we’re  really  trying  to  support  them  in  delivering  optimal  care,  it’s  an  interesting  change  in  the  way  that  we  work  together.  That’s  been  very,  very  helpful.  We  do  provider  satisfaction  surveys  probably  not  as  often  as  we  should  and  we  don’t  do  360  peer  evaluations  on  our  providers  which  I  think  is  another  opportunity.      That’s  something  that  we  did  at  Mayo  that  Mission  doesn’t  do.  They  were  very  transparent.  It  was  multi-­‐disciplinary.   How   does   your   nurse   feel?   How   does   your   colleague   feel?   How  does  your  administrator  feel?  How  does  your  other  partners,  your  referring  physicians,  how  do  they  feel?  We  should  do  more  of  that.      We’ve  been  having  most  of  our  conversations  as  of   late  about  our  patients  and  how  they  feel   about   us.   That   is   a   challenging   metric   to   get   by   from   our   caregivers   because   of  attribution,   because   of   sample   size.   We’ve   been   trying   to   focus   on   satisfaction   of   our  patients  with  our  care  moved  probably  to  a  more  regular  and  more  frequent  physician-­‐to-­‐physician  kind  of  team  survey  but  we  probably  don’t  do  that  as  much  as  we  should.    [Bryan  Oshiro]  Jay,  do  you  feel  like  your  physicians  kind  of  feel  the  same  way  like,  “You  know  what?  We’re  really  in  the  same  boat.  Our  reimbursement  is  really  going  to  be  together  with  the  hospital  and  with  other  agencies  and  so  forth.”    [Jay  Fakier]  I  think  they’re  starting  to  kind  of  see  that.  I  wouldn’t  say  that  everybody  understands  that.  I’m  done.  Do  I  need  to  shut  up  now?      [Bryan  Oshiro]  No,  no.      

[Jay  Fakier]  I  thought  I  was  getting  out  of  it.      [Bryan  Oshiro]  That’s  for  me  to  shut  up.    [Jay  Fakier]  I’ll   talk   five  minutes?  No.   The   toughest   thing   is   actually   sitting   in   this   chair.   I  wish   I   could  stand  up  and  walk  around  and  use  my  hands.  As  time  goes  on,  I  think  that  it’s  important  for  us…    [Bryan  Oshiro]  Wait,  wait,  wait.  And  you’re  a  radiologist?    [Jay  Fakier]  I   know.   Isn’t   that   crazy?   I   know.   I   don’t   know.   I’ll   start   questioning   myself.   I   think   as  physicians  begin   to  understand  that   this   is  going   to  affect  you,   this   is  going   to  affect  your  bottom   line,   as   they   start   to   understand   risk   associated  models   and   how   that’s   going   to  come  down  the  line.      The  main   thing   that   I   try   to   get   across   to   a   lot   of   them   is   “Say   it   never   does   affect   your  practice,   it  only  affects   the  hospital.  Do  you  want  to  work  at  a  hospital   that  goes   into  the  dumps   because   they   can’t   manage   the   books   because   of   the   way   you’re   practicing  medicine?   Are   you   so   cocky   that   you   believe   every   patient   that   comes   to   Thibodaux  Regional  Medical   Center   is   because   you’re   here   and   not   because   we   do   actually   have   a  fabulous  facility?”      I  have   friends   that   live   in   the  neighboring   town   that  bypass   their  hospital   to  come   to  our  hospital  because  it  is  a  fabulous  facility.  I’ll  tell  those  other  doctors.  That’s  kind  of  the  face-­‐to-­‐face  thing  you  got  to  have  with  them  and  say,  “Look,  it  does  take  great  doctors  to  have  a  great  hospital  but   it   takes  a  great  hospital,   too.”   I  don’t   care  how  good  you  are.   If   you’re  working  in  a  dump,  you’re  not  getting  patients.  We  all  got  to  work  to  keep  the  doors  open.  That’s  what  I’m  saying.    [Bryan  Oshiro]  Yes.  Yes.  That’s  amazing.  Awesome!  These  are  just  thoughts,  final  closing  thoughts  on  this  is  just  to  consider,  check  the  pulse  of  your  physicians.  Gauge  them  because  if  you  never  ask  a  question,   you   probably   won’t   know.   Share   the   results   of   what   you   found.   Just   ask   the  question,   they  go,  “Oh,   they  asked   that   last  year  and  nothing  happened.”  “What  did   they  say?”  “I  have  no  idea.”  Share  the  results  of  what’s  going  on.      Then   make   a   determined   effort   to   do   something   about   it.   If   administration   doesn’t   do  something   about   it,   that’s   no   good   either.   If   we   do   want   them   to   something   about   it,  actually  it  is  a  true  partnership  like  Jay  said.  Let’s  do  that.    

Just  a  couple  of  other  best  practices  for  physician  engagement  is  I  think  he’s  right.  Myself  as  a  physician,  I  just  don’t  want  to  get  told  what  to  do.  I  want  to  be  part  of  the  discussion.  Even  if  I  can’t  do  anything  about  it,  at  least  they  had  the  courtesy  to  ask  me.      I  think  that  we  can’t  go  along  this  road  anymore  and  say,  “We’re  not  on  the  same  plane.”  It’s  kind  of   like   if   two  people,  Sue  and  Mabel,  are  sitting  on  a  seat   in  an  airplane  and  say,  “Hey,  Mabel.  It’s  a  good  thing  we’re  sitting  on  the  left  side  of  the  airplane  because  the  right  side  engine  is  blowing  up.”  If  the  engine  fails  on  the  airplane,  everything’s  lost.    Ensure   that   there   are   clear   benchmarks   that  we’re  working   together   and   that  we   can  be  successful  together.  I’ll  just  leave  it  at  that  because  we’re  out  of  time  but  we  have  a  survey  question  or  something  else  going  on.                                                                        

       

 Poll  Question  Number  Two  [32:10]    [Male  Speaker]  We  do  have  a  couple  of  questions.  The  question  is  what  barrier  to  physician  engagement  do  you   see   most   at   your   organization?   A-­‐physicians   feel   overwhelmed   and   ill-­‐equipped   to  implement  change,  B-­‐hospitals  and  payers  believe  that  employing  physicians  is  the  primary  means  of  securing  alignment,  C-­‐organizations  have  the  misconception  that  compensation  is  one  of  the  most  important  drivers  for  physicians  or  D-­‐physicians  have  a  poor  understanding  of  the  risk-­‐based  payment  model,  along  with  being  risk-­‐averse?  I’ll  give  you  a  few  seconds  to  respond  to  that  poll.    Looks  like  41%  responded  overwhelmed  and  30%  said  they  have  a  poor  understanding.    [Bryan  Oshiro]  Okay.  Pretty   interesting.   I   think   the  overwhelmed,   that’s  my  vote,   too.   In  any  case,   thank  you  all  for  coming  and  participating.  Could  you  please  give  a  warm  hand  to  our  panel?          

       

 Analytics  Insights/Questions  and  Answers  [33:41]    [Female  Speaker]  We’re   not   actually   done   with   them   yet.  We   have   some   questions   from   you.   One   of   the  questions  that  rose  to  the  top  is  do  you  have  different  approaches  for  PCPs  and  specialists  and  what  are  the  biggest  challenges  in  either  group  if  you  do.    [John  A.  Merenich]  I’d   love   to   start  off  with   that  because   I   think   that’s…in  our  medical  group,  one  of   the  key  factors,   we   want   to   be   the   best   at   understanding   the   way   primary   care   and   specialists  intertwine  and  deal  with  patients  is  seamless  to  the  patient.  I’m  a  specialist.  I’d  like  to  think  that  I  can  influence  patients  I  never  see.  I  can’t  do  that  in  private  practice.  We  established  this  kind  of  “Call  us.  There’s  no  silly  question,”  so  that  every  patient  feels  like  “Well,  I  talked  to  the  neuro-­‐surgeon  and  I  showed  him  your  films,”  and  that  kind  of  a  deal.    Conversely,  the  specialists  can  take  a  lot  of  things  off  their  plate  that  would  historically  go  in  a  fee-­‐for-­‐service,  maybe  to  them,  and  just  say,  “Hey,  I  could  teach  you  how  to  do  this.”  That  kind  of  interaction  with  the  specialists  and  the  primary  care  physician-­‐to-­‐physician  and  how  it  reflects  in  patient  care  is  probably  one  of  the  top  three  things  that  we’d  like  to  figure  out  because  that’s  going  to  distinguish  groups  in  the  future.  

 [Angela  Wills]  In  the  last  couple  of  years,  we’ve  seen  a  huge  shift  in  our  strategy  and  appreciating  that  the  primary   care,   the   PCPs   really   are   the   future   for   population   health.   We’ve   made   a   huge  investment   in   recruitment,   creating   different   models   of   care,   moving   care   management  from  the  in-­‐patient  to  the  ambulatory.  It’s  been  interesting  to  observe  the  specialists  and  a  little  bit  of  discomfort   in   appreciating   that  PCPs  now  have  a  different  power   in  managing  patients  and  historically  have  had.      There’s   a   lot   of   time   and   intention   just   talking   about   what   is   the   new   model,   what   is  population  health,  how  do  we  work  together,  how  do  we  very  effectively  manage  disease  processes,  and  how  do  we  share  patients  together  in  a  different  way.  It’s  exciting  work.  It’s  important  work  but  it  creates  different  models  and  a  little  bit  of  discomfort.    [Female  Speaker]  Thank  you.    [John  A.  Merenich]  I  was  going  to  add  one  other  thing  to  that.   I   think  the  other  component  of  that   is…I  don’t  know   how   many   people   have   read   Christiansen’s   book   but   how   you   get   primary   care  doctors  to  kind  of  disrupt  and  innovate  into  specialty  space  and  that  model  only  works  is  if,  at  least  in  our  system  is  that  we  have  a  system  and  we  have  to  get,  led  doctors  be  part  of  but  let  go  of  the  empiric  stuff.      We  want  doctors  doing  doctor  work  and  not  spending  time  on  calling  up  somebody  at  night  to  arrange  their   lipotherapy  or  something   like  that.  We  can  have  other  people  do  that  on  their  behalf.  There’s  some  push  back  on  that  because  that  feels  good  but  the  reality  is  just  that  the  numbers  don’t  add  up.  We’ve  got  to  shift  everything  up  and  it’s  not  just  one  thing.  If   you   do   what   I   just   said   with   the   specialists,   pushing   more   back   to   primary   care   and  primary  care  has  no  outlet  themselves  then  you  really  increase  frustration.    [Female  Speaker]  Thank  you.  Another  question  is  how  do  you  handle  negative  push  back  from  physicians  who  have  no  interest  in  being  engaged?    [Jay  Fakier]  I  like  that  question.    [Female  Speaker]  It  has  your  name  on  it.    [Jay  Fakier]  That’s   an  example.   The   first  meeting  when  we  met  with   the  doctors   to   say,   “We  got   this  care   transformation   project.   We   got   this   data   warehouse.   We’re   going   to   look   at  performance  and  all  this  kind  of  stuff.”  I  sat  next  to  one  of  the  urologists  who’s  been  there  30  years  who  I  highly  look  up  to  as  a  mentor  and  go  through  my  questions,  but  I  sat  next  to  him  because  I  knew  he  was  going  to  be  a  problem.    

 The  first  thing  he  did  with  his  stuff  which  was  perfect  because  he  was  a  urologist  is  “I  don’t  want   any  penalization  because   I’m  not  doing   a   good   job.”   That   right   there   I   thought  was  fabulous.  I  said,  “Nobody’s  out  to  penalize  anybody.  This  is  a  concerted  effort  to  get  better  at  what  we  all  do.”    The  next  person  stood  up  and  said,  “Well,  this  whole  data,  you  know  data  could  be  wrong  and  data  could  be  this  and  it’s  all  how  you  interpret  it.”  I  said,  “Well,  Bart  the  beautiful  thing  about  data  is  that  is  that  it’s  doctor-­‐driven  so  you’re  going  to  be  the  first  person  to  look  at  the  data  so  if  the  data’s  wrong,  you  get  to  say  it.  You’re  not  having  some  person  that  was  going  on  talking  to  you  about  it.”    The  third  person  that  stood  up  basically  said,  “Well,  I’m  tired  of  the  hospital  pushing  these  big  old  things  and  then  all  of  a  sudden  you  lose  one  in  60  days  and  we  never  hear  about  it  again.”  I  said,  “No,  we’ve  already  got  people  behind  this.  We’ve  got  money  invested.  We  got  some  more  [Inaudible][38:46].  This  is  going  to  drive  forward.”    Finally  the  crowd  was  exhausted  and  nobody  else  stood  up.  We  haven’t  had  really  that  push  back  problem  since  then.  People  that  we’ve  asked  to  get  involved  and  want  to  get  involved,  they  see  it’s  real.  We  got  the  numbers  from  the  first  project.  It’s  hard  to  argue  with  that.  I  told  you  earlier.      If  you  look  at  the  doctor  that’s  been  practicing  10,  15  years  and  you  tell  him  when  he’s  kind  of  a  naysayer  and  you  say,  “John,  do  you  believe  that  if  you  would  go  back  to  residency  right  now  there  might  be  one  thing,  maybe  one  thing  you  would  do  differently?”  He’ll  go,  “Oh,  probably  a  bunch  of  things.”  I  say,  “Well,  there  you  go.  It’s  exactly  what  we’re  doing.”    [Female  Speaker]  Thank  you  very  much.  We  have  another  question.  How  do  you  effectively  get  buy   in  from  doctors  who  are  already  feeling  threatened  or  overextended?  I  don’t  know  if  it’s  the  same  answer  or  a  different  one.    [Jay  Fakier]  One   thing   for   the  doctors   that   feel   somewhat  overextended,  one   thing   that   I  did   that  did  kind  of  work  is  when  you  came  out  and  you  created  the  whole  word  everybody  hates,  the  bundle,  the  order  set,  the  protocol  or  whatever.  If  it  was  one  that  was  created  by  physicians,  you  have  a  better  adoption  by  physicians.  You  could  look  at  a  physician  and  say,  “Look.”      Believe  me.   I  don’t  approach  a  physician  on   that  kind  of  management  deal  because   I’m  a  radiologist.  I’m  not  going  to  have  some  doctor  look  at  me  and  go,  “Look  here,  don’t  talk  to  me  about  clinical  medicine.”  We  know  better  than  that.  That’s  not  actually  my  role.      If  Paul  who’s  an  infectious  disease  doctor  when  we  did  our  sepsis  deal,  he  was  the  key  guy  because  of  his  experience  to  go  to  those  doctors.  He  could  say,  “Look,  you  talk  about  being  overwhelmed   but   what   we’re   creating   is   a   situation   in   which   we   will   streamline   best  practice  for  sepsis  care  and  save  you  time  and  have  a  better  outcome.  This  will  actually  help  

with  you  being  overwhelmed.  You  just  got  to  put  a  little  effort  up  forth  in  the  beginning  for  things  to  get  better  but  that’s  everything  in  life,  right?”    [Female  Speaker]  Yes,  pretty  much.    [Angela  Wills]  I   would   just   add   to   that   from   the   administrative   perspective   we   do   try   to   really   assign  resources  to  help  physicians  who  are  overwhelmed  whether   it’s  with  tools  or  whether   it’s  with  processes  or  they  just  need  the  right  person  to  do  the  things  that  doctors  don’t  need  to  do.  We’re   very   committed   to   investing   heavily   in   that   space   and   redesigning,   getting   the  right  people  on  the  right  seats  in  the  bus  and  supporting  that  way.    [Female  Speaker]  Great.   I   think  we  have   time   for  one  more  question?  One  more?  Okay.  That   is  do  you  pay  physicians  for  their  involvement  and  if  so,  hourly  or  some  other  way?    [Angela  Wills]  Ooh,  this  is  a  hot  one.    [Female  Speaker]  Yes,  it  is.    [Jay  Fakier]  I’ll  start  off.  We  do.  We  pay  them  on  an  hourly  rate.   I’m  paid  right  now  I’m  sitting  on  this  chair.  That’s  okay  because  one  of  the  problems…    [Angela  Wills]  How  much?    [Jay  Fakier]  One  of  the  problems  I’ve  had  early  on  was  that…yes.  One  thing  I’ve  always  had  issue  with  is  like  if  Toyota  wants  to  figure  out  a  better  way  to  build  a  car  and  they  get  a  whole  bunch  of  people  involved.  They  pay  those  people  to  be  involved.  You  do  the  same  thing  in  medicine  and  you  involve  doctors  and  they  ask  to  be  paid  for  their  time  and  you  have  the  person  at  the   back   of   the   room   that   says,   “Well,   that’s   unethical.   Shouldn’t   you   just  want   to   do   it  because  you  worry  about  your  patient?”    Well,   I   don’t   think   that   I  want   to   be   paid   for  my   time  means   that   I   don’t   care   about  my  patients.     I   care  about   the  people   I  work  with.   I   think   that  we   just  need  to  get   rid  of   that  concept   that   you   should   do   everything   for   free   because   it’s   the   right   thing   to   do.  Well,   I  think  it’s  the  right  thing  to  have  a  nice  car.  Let’s  quit  paying  them,  too.    [Angela  Wills]  I  would   say  we’re   the  opposite   end  of   the   spectrum  at   first.   For   a   couple   of   years  we’ve  been   paying   for   everything.   You   can   put   down   15   minutes   on   a   time   card   because   you  thought  about  an  article  and  you  get  paid.  We  have  different  rates  for  different  specialties.    

 What  we’re   trying   to  do  now   is   really   look  at  what  are  our   leadership   roles,  what  are   the  outcomes  they’re  responsible   for.  Let’s  give  them  enough  time  to  do  the   important  work.  Let’s  compensate  them  in  a  fair  way,  what  they  would  earn  if  they  were  seeing  patients  and  let’s   just   get   aligned   rather   than   the   15-­‐minute,   half-­‐hour   kind   of   fill-­‐out-­‐a-­‐time-­‐card   and  someone  has  to  sign  off  and  approve  that.  Just  changing  to  a  different  model,  giving  time,  paying  fairly…    [Jay  Fakier]  That’s  exactly  right.    [Angela  Wills]  …and  being  aligned  in  what’s  the  work  that  we  expect  to  accomplish  together.    [Female  Speaker]  John,  you  get  the  last  word.    [John  A.  Merenich]  Okay.  I  think  we  much  have  the  same  kind  of  approach.  Give  time  out  of  the  clinical  time  so  that  you  can  participate  in  the  many  meetings  and  the  work  with  health  plan  and  doing  the  evidence-­‐based  guidelines.  We  compensate  in  that  way.  I  think  the  other  thing  that  we  very  rarely  give  overtime  pay  for  this  kind  of  thing.  We  do  have  incentives  at  the  end  of  the  year  from  the  health  plan  but  we  receive  them  as  a  group.  It’s  all  or  none.      We   have   1,000   physicians.   We   all   get   the   same   quality,   service,   and   affordability,   more  affordability   this   year   than  ever  before.  As  we  meet   these  expectations   as   a   group   that’s  how  we  compensate  for  how  as  a  group  we’ll  handle  this.  That  kind  of  really  gets  us  to  work  together.      I’ll  finish  with  this.  It  was  on  your  survey  question.  Most  doctors  are  pretty  happy  with  what  they  make.  What  they  want  is  control.  They  want  some  autonomy.  They  want  to  be  able  to,  “Give  me  the  job  to  do.  Let  me  figure  it  out.  Don’t  micro-­‐manage  me.”  We’re  really  trying  to  de-­‐centralize  our  control  mechanisms  even  in  the  last  couple  of  years  to  accommodate  that.                              

     

 Thank  You  [44:37]    [Bryan  Oshiro]  Well,   thank  you  so  much.  We’re  out  of   time   for  questions.   Let’s  give   them  another  hand.  Don’t  leave  just  yet  because  there’s  some  housekeeping  issues  I  think  that  we  have  to  talk  about.  Later  tonight  if  anybody’s  interested,  7:30  Jay’s  having  a  comedy  stand-­‐up  show.                                

     

 

 Lessons  Learned/Choosing  One  thing  [44:53]    [Female  Speaker  2]  All  right.  On  the  table  in  front  of  you  there’s  a  “Lessons  Learned”  sheet.  We’re  going  to  ask  you  if  you  would  fill  out  the  “Just  One  Thing”  on  there  that  would  be  what  you’re  going  to  take  from  this  wonderful  presentation.  I  thank  our  speakers  again.  While  you’re  filling  that  out,   our   analysts   have   come   up  with   some   insight   based   on   your   poll   questions.   They’re  going  to  go  over  that  with  you  right  now.    [Female  Speaker]  We  didn’t  get  a  chance  to  focus  as  much  on  the  polls  during  this  session  but  we  just  wanted  to  give  you  some  fun  facts  about  the  individuals  in  the  room  for  this  particular  session.  What  we  found  was  we  had  a  very  pertinent  audience  for  this  session.  Over  53%  of  the  individuals  in  the  session  identified  as  clinicians.  Of  those  individuals,  most  people  said  that  they  have  been   in  health   care   for   five   to   ten  years  and  most  of   those  people  as  well   said   that   their  organization  was  about  250-­‐500-­‐beds  large.    I’m  going  to  share  some  applause  insights  with  you  to  show  how  we  spiked  plot  rest.  Most  of  it  was  when  the  gentleman  in  the  cowboy  boots  stood  up  to  speak.    [Male  Speaker  2]  For  the  first  spike  here  at  18  is  how  do  we  get  buy  in?  How  do  we  get  our  peer  groups  to  get  in  on  the  vision  that  we  have  and  to  create  that  motivation  to  work  as  a  group.  The  next  one  here,   I   just   want   to   point   it   out   is   the   personality   disorders.   As   we   learn   to   work   with  

personality  disorders,  I  think  we  all  deal  with  our  own  at  times.  Then  57,  of  course  when  you  stood  up  and  got  engaged.  There  we  have  with  applauses.