Inflation has hit healthcare particularly hard, as supply and labor costs increased significantly in the last year, but reimbursement rates haven't kept up. Health systems are now finding creative ways to add revenue streams and cut costs without hindering patient care.
Becker's asked C-suite executives from hospitals and health systems across the U.S. to share their plan for weathering the financial challenges of today and setting their organizations up for success in the future.
The 62 executives featured in this article are all speaking at the Becker's Healthcare 11th Annual CEO+CFO Roundtable on Nov. 13-16, 2023, at the Hyatt Regency in Chicago.
To learn more about this event, click here.
If you would like to join as a speaker, contact Mariah Muhammad at mmuhammad@beckershealthcare.com or agendateam@beckershealthcare.com. For more information on sponsorship opportunities, contact Jessica Cole at jcole@beckershealthcare.com.
As part of an ongoing series, Becker's is talking to healthcare leaders who will speak at our conference. The following are answers from our speakers at the event.
David Callender, MD. President and CEO of Memorial Hermann Health System (Houston): At Memorial Hermann, we have been focused on removing costs and reducing expenses since well before the pandemic. In fact, lowering the cost of care is one of our system's key strategic initiatives. Two programs that we are particularly proud of are our Structuring for the Future and Clinical Care Redesign initiatives.
Our Structuring for the Future initiative, launched in 2016, emphasizes sustainable growth focused on quality, service, and cost. By taking a measured approach to reduce our average length-of-stay, being mindful of our overall supply costs, finding solutions that will help eliminate patient denials based on capacity issues, and improving labor productivity, we have removed nearly $1 billion in cost over a six-year period. A portion of that cost savings — approximately $236 million — can be attributed to our Clinical Care Redesign initiative, which has also helped to reduce cost, eliminate care variation and expedite our shift to value-based care. By implementing new clinical pathways, deploying multidisciplinary discharge rounds and standardizing surgical supply packs, for example, our system is improving patient outcomes and driving down the cost of care.
The success of these initiatives — made possible by a fully-engaged leadership team and in close collaboration with our frontline caregivers and physician partners — has allowed us to improve our financial performance and set a stable baseline for the future.
David Lubarsky, MD. CEO and Vice-Chancellor, Human Health Sciences of UC Davis Health (Sacramento, Calif.): Thankfully, our margins did not shrink last year, and we were able to grow our revenue while keeping costs down. We have also been redoubling our efforts to be an employer of choice, so our workforce turnover has been low, allowing us to keep contract labor costs in check. We are keeping a close eye on hiring to make sure every FTE being hired is truly necessary.
We have also been working to lower supply costs by reducing stockpiles where they are not necessary and standardizing items where physician preference doesn't play a part in item selection (such as lights, booms, etc.). We have also been reducing our real estate footprint, shedding expensive office leases and consolidating them into owned buildings, and moving some back-office services to less expensive real estate options in suburban parts of the metro area.
Wendy Horton, PharmD, MBA. Chief Executive Officer of UVA Medical Center (Charlottesville): At UVA Health, we are committed to reducing costs and innovating healthcare delivery by investing in our teams, redesigning care delivery, and increasing access for patients and our community. We recognize the challenges the healthcare industry face provide an opportunity for radical paradigm shifts to increase efficiency, and we understand that many pivots and course corrections are needed to maintain a positive financial outlook. We are implementing pipeline programs, leveraging technology, and creating flexible workforces to support our teams. We are also modernizing care delivery and patient progression, focusing on essential areas like our emergency department. We’re in the midst of a multi-year initiative that will transform outpatient access and deliver a consistent patient experience while enhancing provider satisfaction. Most importantly, we remain dedicated to our mission of transforming health and inspiring hope for all Virginians and beyond.
Bill Gassen. President and CEO of Sanford Health Plan (Sioux Falls, S.D.): I'm proud of the way our people and leaders have driven our performance this past year, which has been relatively strong compared to most health systems nationwide. Sanford Health has leaned into solving the challenges of rural care delivery by prioritizing investments in our workforce and new innovative care delivery models. These efforts have positioned us for the next era of healthcare.
We have made an unprecedented expansion in our graduate medical education programs to bring clinical expertise, resources and subspecialties to the upper rural Midwest. In partnership with universities across our region, Sanford Health will fully fund 15 additional residency and fellowship programs, which will train more than 300 residents and fellows a year. Expanding the number of medical residency training programs in rural areas is key to filling gaps in care.
We are also investing in innovation to help our nurses do their most fulfilling work and improve care outcomes. For example, we are using predictive analytics to more precisely schedule clinical staff based on patient demand forecasting. Last year, our team developed a new tool called LAMP, Leveraging Analytics to Mobilize (our workforce) and Prepare (for the future), which offers insights into our clinical workforce needs allowing us to optimize future staffing and scheduling decisions. LAMP has helped to improve nursing job satisfaction and saved each scheduling manager 40 hours per month.
With two-thirds of our patients living in rural areas, we are committed to ensuring they have access to high-quality care no matter where they live or the health challenges they face. Over the last decade, Sanford Health has provided more than 650,000 virtual consults with patients, saving 25 million miles of travel while receiving high-quality care. Our $350 million virtual care initiative will fundamentally transform how we deliver care by expanding access, improving the patient experience, advancing innovation through new research, attracting and training a new generation of clinicians and sharing learning opportunities through an education institute.
With both challenges and opportunities confronting us, our industry sits at an important crossroads. I am excited about the possibilities ahead. I believe rural health systems are uniquely positioned to advance innovation and deliver on the promise of better health for all.
Chris Allen. Interim CFO of Keck Medicine of USC (Los Angeles): Calendar 2022 was uniquely difficult for Keck Medicine of USC. With a June 30th year-end, we saw a tale of two halves of the fiscal year, with growing volumes close to pre-pandemic levels from January to June. This required us to bring on an even larger contingent of contract nurses to manage census levels in our academic hospital and our community hospital, which began to see volumes increase in the emergency room.
At the same time, we began dealing with labor shortages and increasing wage rates for union employees as well as market pressure to retain employed staff. All while we were preparing to add a new community hospital to our system and the cost associated with this initiative. We needed to prepare for the growing impact of payer denials related to authorizations for admission, level of care, and challenges with ongoing case management issues around discharge availability to post-acute care facilities.
By late summer, we saw our margins, for the first time in years, drop to an overall negative system operating margin. On pace to have variances from budget approaching $100 million. As a health system, we embarked on a 90-day internal assessment of opportunities and actions we could take to recover from losses through Q2 of our fiscal year. These included the following categories:
- Revenue cycle review
- Strategies to reduce labor cost
- Review of all capital projects
- Review of Consulting and service engagements
- Untapped growth opportunities
- Pace of hiring in non-beside care areas
In 90 days, we quantified over 60 initiatives totaling over $80 million in margin impact. We focused on the following opportunities for the remainder of the fiscal year.
- Reduction of nursing contract labor/ negotiated rate reduction on an hourly rate.
- Pause of capital projects that have not been kicked off to decrease IT contract labor.
- Pause on non-beside care FTE request (replacement and new).
- Pause on marketing engagements using external firms.
- Pause/Reduction in consulting engagements.
- Focused initiative to increase use of Keck Medicine Specialty Pharmacy.
- Initiate a Kizan on registration and authorization of elective surgical cases.
Paul Hinchey, MD. COO of University Hospitals (Cleveland): Like others in the healthcare industry, University Hospitals has been confronted by significant economic challenges this past year. In response, we've formed multi-stakeholder teams focused on expense and services optimization. Clinically, we're rethinking how and where we deliver care. One great example is our growing Hospital@Home program. Combined with an intense focus on early discharge and improved throughput, the program reduces the workload on the hospital team and helps restore the balance between the supply of caregivers and the demand for care.
Our Care Team of Tomorrow initiative is redefining the roles of our caregivers and identifying and reducing nonessential tasks that don't contribute to the delivery of high-quality, safe patient care. This allows us to redesign roles to ensure everyone plays a part and operates at the top of his or her ability, whether it's nurses, pharmacists, Patient Care Nursing Assistants, environmental services or food and nutrition professionals. By doing so, we create more efficiency with regard to staffing.
We are also investing in shifting our care delivery to higher efficiency, lower cost sites of service as a means of increasing value for our patients. For example, we broke ground last November on a new ambulatory surgery center that will comprise five operating rooms and one procedure room and will focus on orthopedic surgical procedures, with the capacity for 800 total joint replacement cases per year. These are all investments to increase the value of the care we provide, not merely cut costs. They work together to help us serve our patients well into the future, despite any continuing economic headwinds that may arise.
John Cacciamani. President and CEO of Chestnut Hill Hospital, Temple Health (Philadelphia): There are a few things I'm doing to reduce costs: (1) Reduction in agency with aggressive recruitment, particularly in nursing; (2) For those paid at the market [rate], the reduction of bonus pay across the board; (3) Considering closure of service lines with low margins to help reduce the above issues by reallocating staff and talent; and (4) Very hard look and supplies and pharmacy expense to look for opportunities.
Sarah Morrison. CEO of Shepherd Center (Atlanta): To reduce costs, many hospitals are forced to lay off workers. Shepherd Center cannot afford to lay off our staff because they are experienced and highly proficient in treating our very unique patient population of spinal cord and brain injuries. Instead of laying off workers, we are looking at all vacant positions to determine if we will backfill those positions. Additionally, we are turning over every rock in regard to finding opportunities to reduce costs and/or improve revenues.
Paul Taylor, JD. CEO of Ozarks Community Hospital (Gravette, Ark.): As the CEO of a critical access hospital with a dozen provider-based rural health clinics, I cannot provide a straightforward answer to that question. We are cost-reimbursed by Medicare and Medicaid, which are our largest and best payers by far. We have had negative operating margins for years. If we cut costs, we will owe money back to the government, which we will not be able to pay in a lump sum.
The government will 1) reduce our reimbursement to reflect those lower costs, and 2) set up an extended payment arrangement for the cost report settlement we could not pay, doing so over three years at a high rate of interest, which it will recoup from each remit further reducing our cash flow. We focus on cutting those expenses which are not allowed on the cost report and in those service departments which have proportionally fewer governmental patients.
Tom Mee. CEO of North Country Healthcare (Whitefield, N.H.).: While it may sound counterintuitive, North Country Healthcare increased wages as well as implemented socially responsible minimum wages. The impact of this was a lessening of our reliance on traveling staff.
Jennifer Schneider, MD. Co-Founder and CEO of Homeward (San Francisco): As a value-based care provider, we prioritize high-quality care focused on preventative services that drive improved quality of life and financial efficiencies. With this in mind, Homeward partners closely with communities and health plans to build upon existing relationships with providers and health systems in small towns and rural areas.
We are keen on leveraging technology to support healthcare professionals so they can practice at the top of their licensure to minimize administrative burden, improve satisfaction, and connect with more members in need of care. In addition, we leverage technology-scale access to quality telehealth care without requiring members to travel long distances to be seen.
Paula M. Ellis, DNP. Interim CEO of F.W. Huston Medical Center (Winchester, Kan.): My first move in reducing costs when I became interim CEO of a rural critical access hospital was to wean directors from using agency staff. During the pandemic, using agency became "the way" of doing business that we could no longer afford. Secondly, I instituted productivity standards for all departments and monitored adherence requiring staff to match volumes. A third tactic was to reduce administrative costs by eliminating and combining managerial positions.
William Morice, MD, PhD. President and CEO of Mayo Clinic Laboratories, Mayo Collaborative Services (Rochester, Minn.): Throughout healthcare, we face financial challenges and downward pressure on reimbursement. In response to this, at Mayo Clinic Laboratories, we are taking both near-term and intermediate-to-long-term measures to lower our cost structure.
Near-term tactics include lowering supply chain expenses by working internally to identify opportunities for standardization and engaging our vendors to form strategic alliances, using business intelligence to optimize instrument utilization, and instituting daily huddle boards with our front-line staff to improve operations. To lower costs over the longer term, we will be instituting process automation, implementing HR strategies to reduce contract labor, and identifying and implementing best practices on instrumentation procurement and replacement.
Brian Peters. CEO of Michigan Health Hospital Association (Okemos): As Michigan's state hospital association representing all acute care community hospitals, we're focused on what legislative and regulatory relief we can provide to our hospitals to reduce costs. Labor expenses exploded in recent years due to the need to rely on contract labor and recruitment expenses. Hiring new staff is always more expensive than retaining existing workers. We have assisted our hospitals in this area by securing $300 million in state funding over the past two legislative sessions to support the recruitment, retention and training of healthcare workers to reduce the reliance on contract labor and recruitment costs.
We were also successful in modernizing the scope of practice for certified registered nurse anesthetists, which allows flexibility for each hospital to choose the anesthesia care model that best fits its location, staffing and resources.
Lastly, our association has been routinely convening our hospital supply chain leaders since the beginning of the pandemic to engage in shared learning on effective strategies and to connect them with preferred group purchasing partners to identify available resources and supplies at lower rates.
Shlomit Schaal, MD, PhD. Executive Vice President and Chief Physician Executive of Houston Methodist (Texas); President and CEO of Houston Methodist Physician Organization (Texas): Our health system has taken a multifaceted approach. We are investing in technology to automate manual processes, such as appointment scheduling and patient registration, which will help us save on labor costs. We are also implementing initiatives to reduce waste and optimize our supply chain, such as using data analytics to identify opportunities to improve inventory management. Additionally, we are focusing on delivering high-quality care in the most cost-effective way possible by leveraging value-based care models and working closely with payers to ensure we are delivering the right care at the right time. These strategies will enable us to reduce costs while still providing the best care for our patients.
Michael Coyle. CEO of Veterans Memorial Hospital (Waukon, Iowa): At Veterans Memorial Hospital, we started to aggressively price shop areas, including Bio-Med, GPO and service contracts. We also started to enhance our cross-training education for staff so we could limit the amount of FTE usage. Finally, we examined our staff turnover, identified organizational cultural issues that led to turnover and implemented a variety of strategies to be the provider of choice in the region. The result was increased organizational loyalty and increased overall employee engagement.
Eilidh Pederson. CEO of Western Wisconsin Health (Baldwin): (1) Remain focused on strategic plan; (2) Focus on internal workforce and eliminate all agency staff (i.e., travelers) (3) Empowering leaders to be creative with where they say 'no' and thus, reduce expenses that are not adding value (4) Renegotiating vendor contracts.
Jandel T. Allen-Davis, MD. President and CEO of Craig Hospital (Englewood, Colo.): It is a challenging time for healthcare and one that is not likely to significantly improve in the short run. We have moved to a narrower network benefit for our employee health insurance plan, are scrutinizing each vacant position prior to posting and are working with our payers on contract renegotiations to demonstrate the value of Craig Hospital.
Melisa Adkin, BSN, RN. CEO of Uof L Health – Mary & Elizabeth Hospital (Louisville, Ky.): Over the last couple of years, we have been working with an international program to bring in a variety of additional healthcare workers into our system and the community. This has helped to offset some of the labor challenges that we and all other healthcare systems have faced. Even though it did not help fill the entire gap, it did help provide some relief for our staff during these difficult times. Starting an internal float pool has also been very helpful in recruitment and retention. In the end, being creative, and managing contract labor and supply costs, among other things, have been imperative to making sure our system moves forward and stays financially strong.
Chris Bjornberg. CEO of Mayers Memorial Healthcare District (Fall River Mills, Calif.): We are looking at several low-hanging fruit areas like I'm sure most other organizations are as well. These would be things like how we are budgeting and reviewing GPO and looking at other possible vendor changes. However, the bigger area that we're focused on right now that we believe will have a larger impact on reducing expenses for our organization is retention. Because of our rural location, it becomes very difficult for us to be able to find well-trained, qualified team members. As a result of this, we have to do a much better job of retaining those individuals that we currently have working with us. Both turnover and utilization of agency nurses, although the price is finally coming down, are very costly for our organization.
So what are we doing regards to retention? We put together a retention/recruitment committee to look at what we're currently offering and what we could change. We started with the nursing department since they are the largest group in our organization and they make up the majority of our agency usage. All ideas were welcome, and we really wanted to look at things outside of the norm. We wanted to be able to differentiate ourselves from others in the area.
We started with the nurse leadership team and put together the foundation for this program together. After we had the foundation of the program in place, we took it to the frontline nursing team and allowed them to pick it apart. This program was months in the making and turned out to be a great exercise for us. It allowed us to put together a robust and well-received program. The program is in full swing now and while it is too soon to tell how successful it will be, it is started off extremely well for us and it looks very promising at this point.
Ronda Lehman. President of Mercy Health - Lima (Ohio): There are numerous things we are doing to re-evaluate the costs in healthcare. Several include looking at outside partners who have expertise in specific services to collaborate for a less costly and even enhanced patient experience. We are becoming increasingly laser-focused on what we do well — providing direct care — and looking to other options for the various other tasks needed to deliver this care.
We are also piloting new models of care, both with virtual care and a different skill mix. We believe the nursing shortage isn't going away anytime soon, and we need to be creative and practical about how to address this very significant issue.
Finally, it is imperative that payers, legislators and the public understand the serious issues that healthcare is being faced with. Our cost structure has dramatically shifted, with minimal to no increase in reimbursement to offset the supply chain and nursing expense issues. There must be a middle ground to balance responsible, cost-effective care and the payment systems we rely on.
Pradeep V. Kadambi, MD. Professor, Department of Medicine, Senior Associate Dean for Clinical Affairs of UF College of Medicine – Jacksonville; President and CEO of University of Florida Jacksonville Physicians: There are a few actions to reduce costs: (1) For remote team members, [we] eliminated office space and saved on rent/real estate costs. For hybrid workers who come on site for two days or less per week, eliminated dedicated office space and promoted the hoteling concept for shared space. (2) Promoting automation in areas such as referral management, scheduling, some areas of the revenue cycle and not filling all the vacancies. (3) Closed a few practices and reassigned the patients to our nearby practices and ramped up telemedicine to ensure healthcare access.
Troy Simonson. CEO of Proliance Surgeons (Seattle): Independent physician practices are not immune to the external market pressures that impact health systems. However, without the constraints of large infrastructures, independent physician practices are able to pivot and evolve efficiently and maintain high-quality, cost-effective healthcare. Proliance Surgeons' focus is on innovative strategies that create operational efficiencies, evolve the delivery of healthcare and create value for the patient.
One of our strategies has been to create partnerships with like-minded practices and recently formed PELTO Health Partners with EmergeOrtho and OrthoIndy. PELTO is focused on creating value for physician practices and patients and sharing best practices.
Rick Shumway, MHA. President and CEO of Stanford Health Care Tri-Valley (Pleasanton, Calif.), Stanford Medicine Partners: Given the ongoing cost escalations lines that don’t appear to be bending anytime soon, it is clear that organizations will need to think differently about how to approach this key issue for future viability. Specifically, we’re doing a number of things that we’re at Stanford Health Care and Stanford Health Care Tri-Valley to address these issues, but one of the most important is our continued participation actively as a Vizient member. This allows us to benchmark our cost performance in very specific ways against our peers at both granular and aggregate levels. It also allows us to address any variances we see by connecting with our peers to learn what others are doing to achieve high levels of performance. This visibility helps us to proactively manage these trends in ways that are both sustainable, but also don’t negatively impact quality performance in the process.
Tom Siemers. President and CEO of Wilbarger General Hospital (Vernon, Texas): We focus on three primary areas:
1. Reduce daily operating expenses. We're challenging each department to reduce operating expenses by 2 percent without layoffs.
2. Reduce overtime. We've eliminated the use of travelers. Now we need to reduce our overtime. The goal is 2.5 percent.
3. Improve case management. Better management of our patients will reduce our costs and improve our revenue.
Mitchell Schwartz, MD. Chief Physician Executive of Luminis Health; President of Luminis Health Clinical Enterprise ( Annapolis, Md.): The pandemic is over, but the lingering impact has changed the business model for health systems. Unlike consumer goods, which can often be priced appropriately for the cost, healthcare pricing is inelastic.
This creates fundamental challenges when abrupt increases in costs, inflation and staffing all hit at once. Health systems like Luminis Health, a nonprofit health system in Maryland, need to embrace the challenge and reassess the following:
1) Organizational structure – scope and accountability defined to ensure the efficient ability to execute strategy and operations
2) Revenue cycle – collect the money owed in a timely manner
3) Efficiency – productivity and throughput need to be improved all while maintaining quality and patient experience
This work is hard – but essential.
Robert L. Meyer. President and CEO of Phoenix Children's (Ariz.): Cost discipline has been an essential focus of the leadership of Phoenix Children's since it became a freestanding children's hospital 20 years ago. Our approach to managing cost is a mix of traditional operational rigor and longer-term innovation.
Phoenix, unlike many cities, is experiencing extraordinary population growth, which translates to increasing numbers of patient families and volumes. Ensuring we have a capable, committed workforce is our number one priority as we continue to grow our system of care to include two new community hospitals and an emergency department at what will be our third.
With the cost of recruitment skyrocketing, we are focused on employee retention and building more efficient pipelines of new talent. We are investing in programs to improve our employee wellbeing and we were recently ranked 17th in the Healthiest 100 Workplaces in America.
We're also focused on developing the next generation of clinicians. Through a partnership with Arizona State University, we have developed a pediatric-specific Bachelor of Science in nursing and licensed clinical social workers. These programs have been tremendously successful, not only at bringing us great talent, but they also require far less training time because the majority of their clinical rotations have been with Phoenix Children's instead of with adult hospitals.
As a growing system of care, we're building our new sites of service in strategic ways that anticipate future expansion and are more affordable in the long run. For example, earlier this year, we built out a new inpatient floor — and we're working on a second — constructed as shelled space more than a decade ago when we opened a new main patient care tower.
Together, these floors will give us 96 new inpatient beds that would have cost tens of millions of dollars more to build through an addition. We are taking that same approach and building shelled space across our expansion projects throughout the Valley, ensuring we can efficiently add capacity we know we will need by our growing community.
Another focus for Phoenix Children's is patient quality and safety. At a time when talent is at such a premium, we need to make sure every employee is spending time on the right things. That is why we have invested in initiatives like WATCHER, a first-of-its-kind digital data surveillance program that uses a predictive algorithm to forecast children at risk of rapid deterioration. We have also built pediatric-specific clinical dashboards to make sure we are delivering the best care in real-time. These efforts are aimed at preventing harm and ultimately reducing unnecessary healthcare costs and spending.
Helen Johnson, RN, MSN. President of Sparrow Eaton Hospital (Charlotte, Mich.): A few things Sparrow Eaton Hospital has undertaken to address the pressures described hearken back to partnerships or skills we may not have drawn upon for some time. Labor challenges are a long-term fix and for the last few years, healthcare has been in a frantic cycle of reliance on contract staffing.
Building great relationships with educational institutions to fill up the pipeline for future hires is crucial, and by this I mean you have to start thinking about encouraging people in high school, maybe even sooner, to look at healthcare as a career. This involves more than nurses and doctors; we have gaps in all areas of the healthcare system: phlebotomy, radiology, surgery scrub techs, etc. Healthcare had many years where we were looked at as a growing and attractive field. COVID-19 changed that reputation and we need to build it back.
As a critical access hospital in a more rural setting, there has not been a disproportionate reliance on inpatient volumes for many years. For most critical access hospitals, our business is heavily outpatient and we are continually improving how we create efficiencies and quicker access to these services. Leveraging Sparrow Eaton Hospital's proximity to our main hospital and larger population base has been key to our achievement of a +15 percent operating margin in 2022.
Thomas Chickerella. Regional CEO of Managed Supply Services at HCA Healthcare (Nashville, Tenn.): My comments reflect the activities of many IDN's that I work with on a consultative basis, not specifically HCA. Here are a few things to reduce costs: (1) labor expense is by far the biggest driver, with flat inpatient volumes, and really not a big impact from inflation outside of labor as of yet; (2) for labor, expanded retention and hiring strategies for RNs and techs, rationalizing contract labor contracts to reduce rates, expanding support services for RNs to allow for work at the top of license; (3) some limiting of choice for supply in high physician preference items; moving from multi to dual, or dual to sole vendors in PPI space; and (4) growth of outpatient services as a result of revenue shift from inpatient to outpatient.
Leslie Wong, MD. Chief Kidney Health Officer of Intermountain Healthcare (Salt Lake City): There has been a deliberate streamlining of leadership and operational structures to maximize efficiency and target specific cost savings in defined areas (e.g., revenue cycle, staffing, etc.). It's up to the various business units to organize efforts individually around these defined financial targets. One major area of focus is the prioritization of ongoing and planned service line projects, with the reallocation of shared data and analytics resources to those top priorities.
Shelly Schorer. Division CFO of Dignity Health (San Francisco): We continue to work on labor efficiencies with stringent position control practices, productivity accountability and consolidation of duties in nonpatient care areas where it makes sense. We have divisions in our organization and we consolidate the work by division and market where we can and by national teams where that makes sense as well, like areas of supply chain, food and nutrition and environmental services leadership.
We continue to have task force teams that work on our length of stay and throughput challenges in the acute setting. This continues to be challenging for acute care hospitals to place patients in the appropriate post-acute setting. We continuously evaluate home health, skilled nursing, hospital at home and advancing care-to-home opportunities. Patients in the appropriate care setting are not only more efficient from a cost perspective but from a quality and patient care perspective. We have best practices that have demonstrated effectiveness in appropriate length-of-stay management that include multidisciplinary rounding, evaluation of consultation timing from orders, planning ahead of discharge for placement with care coordination teams and families and building relationships with post-acute care facilities.
We have a national focus on services transformation that works diligently and together to improve discretionary spending, supply chain, record storage, contracted fees, and other shared or similar services. By leveraging national and divisional expertise, we are able to make faster adjustments and improvements throughout the organization by working together to address challenging spending categories.
Amanda Buirge. CFO of Roxborough Memorial Hospital & School of Nursing (Philadelphia): Roxborough Memorial Hospital's leadership team has been focused on reducing and hopefully eliminating all agency/travelers by the end of July/August of 2023. The C-suite has put together a position control process that assists our team in evaluating each vacancy to determine if the need is still relevant before filling the position. We have also put stricter financial clearance policies and procedures in place while adding and exploring new service line opportunities for the hospital.
Darryl Linnington. CFO of Hollywood Presbyterian Medical Center (Los Angeles): We've been doing these three things: (1) negotiating hard for better terms with vendors, (2) making vendor and product switches and (3) discontinuing services with negative margins.
Nicholas Barcellona. CFO of Temple University Health System (Philadelphia): Like many others, our health system has faced financial pressure this fiscal year. One critical area of focus is to reduce expensive agency staffing for nursing, techs and many other positions by investing in recruitment and retention while holding clinical leaders accountable to enhance productivity. We are also partnering with physician leadership to reduce the length of stay to create capacity for growth. A third area of focus has been on reducing consulting spend, with the CEO and CFO both reviewing every single existing and new consulting engagement to ensure the system is achieving maximum value when engaging outside help.
Herman Williams, MD. Chief Medical Officer of Nashville General Hospital (Tenn.): Here are some actions to reduce costs: (1) be more flexible with the workforce and meet the demand for a "hybrid" workforce, allowing both on-site and remote employment opportunities where appropriate, (2) reduce contract labor and cater to our full-time employees and (3) offer remote services to our patients to meet their new "hybrid" virtual needs.
Jimmy Chung, MD. Chief Medical Officer of Advantus Health Partners (Cincinnati): We believe that the cost of care can be reduced by optimizing the quality of care through improving efficiency and reducing waste. Focusing on eliminating unnecessary variations in care delivery will reduce medical errors and patient harm while improving the patient experience.
We have been successful in reducing the cost of medical devices and purchasing services through consolidation and leveraging the success of our supply chain program. We have developed strategic partnerships with large suppliers to reduce the cost of med/surg supplies and streamline our cardiovascular service lines.
Jeffrey Hoffman MD. Chief Medical Officer of Cambridge Health Alliance (Mass.): The Cambridge Health Alliance is facing many of the same problems other healthcare systems are experiencing, including labor challenges with travelers, a shrinking provider workforce and inflation. To combat this and bend the curve, we are focusing on increasing efficiency in our institution with streamlined care.
We are actively working on and fine-tuning access and schedule utilization with template management, improving provider days by minimizing asynchronous work and developing processes for an appropriate place of care with nurse advice and same-day tele-visits. We are also looking to consolidate and centralize services to reduce redundancies in the workforce and attempt to have people work to the top of the scope of their practice.
Paul Casey, MD. Senior Vice President, Chief Medical Officer; Interim President of Faculty Practice Group; Professor, Department of Emergency Medicine of Rush University Medical Center (Chicago): While the past year has certainly brought economic challenges on the tail of the pandemic, we have been successful in continuing to focus on operational efficiencies to control costs. Fortunately, the financial challenges imposed by agency labor costs have subsided somewhat and been replaced by innovative solutions such as our internal staffing agency. We are also investing in our digital strategy to drive both a better experience for our patients and our teams, but also efficiencies by driving out the mundane tasks that are not top of license for our teams. What has not changed is our unwavering commitment to improving the health of the individuals in the diverse communities we serve and investing in what is most important to Rush our team.
Gian Varbaro, MD. Chief Medical Officer and Vice President of Ambulatory Services of Bergen New Bridge Medical Center (Paramus, N.J.): We are trying to decrease costs in a number of ways, including trying to decrease labor costs by actually spending more on retention so as not to incur search costs and by partnering with innovative companies to recruit permanent staff instead of temporary staffing that we needed the last few years.
George Sauter. Chief Strategy Officer of John Muir Health (Walnut Creek, Calif.): Three things we are doing to reduce costs are improving health system throughput, especially hospital ALOS, consolidating operations management, downsizing management and postponing/canceling investments and projects that do not meet an "ROI within 12 months" threshold.
Susmita Pati, MD, MPH. Chief, Primary Care Pediatrics and Chief Medical Program Advisor, The Alan Alda Center for Communicating Science of Stony Brook (N.Y.) University: Our organization is undergoing a comprehensive strategic planning process to identify areas for growth, improve efficiency, and support workforce retention. Senior leadership initially engaged a consulting firm to help launch this process and is now connecting with service-line leaders in collective brainstorming sessions. Supporting workforce retention is a key theme across all areas and our organization is leveraging our multidisciplinary expertise (i.e., nursing, medicine, psychology, science communication) to implement innovative approaches to build healthcare team cohesion that, in turn, will positively impact workforce retention and organizational resilience.
Eric Tichy, PharmD. Division Chair of Pharmacy Supply Chain at Mayo Clinic (Rochester, Minn.): We are critically looking at the services we provide to understand if there are any low-value services where we are taking losses that we can discontinue. We are also challenging our suppliers to ensure that we have reasonable prices for our medical, surgical and pharmaceutical supplies. With the economy tightening over the last year, we are finding that there are opportunities to improve pricing, especially for products where demand has sagged substantially now that the pandemic has been effectively over for the past year.
Chad M. Teven, MD. Reconstructive Microsurgeon and Clinical Assistant Professor, Surgery Department of Northwestern University Feinberg School of Medicine (Chicago): Like most other healthcare systems, operating margins at our institution have become slimmer. To address this, several approaches are being taken. First, we continue to identify strategies to effectively recruit and retain talented individuals across all aspects of the health system. Labor shortages can be a barrier to offering necessary medical care and services to our patients, and labor turnover is a huge factor in cost increases.
Finding empathically centered ways to find and keep staff is integral. In addition, we rely on both standing and ad hoc value analysis committees to help make decisions on purchasing new equipment, capital expenditures, and more. Finally, when feasible, we look for opportunities to standardize equipment and contracts, as an overabundance of vendors and suppliers can be costly and inefficient.
Peter Odenwald. COO of Luminis Health Clinical Enterprise (Annapolis, Md.): At our organizations, we are 1) analyzing, evaluating, and flattening (where appropriate) the management span of control, 2) maximizing the deployment of technology to highly reliable, repetitive job functions reducing staffing 3) renegotiating ALL contracts for supplies, payers, providers, and real estate.
Chad Dilley. COO of IU Health Saxony (Fishers, Ind.): We know we can't impact national phenomena like inflation, but at IU Health, we can be laser-focused on those things we can control, such as how we continue to nurture a supportive culture of values-driven excellence where we keep our talent, reduce expensive turnover and decrease our dependence on contract labor support. We can also control how consistently and diligently we work toward improving our access, efficiency and throughput to ensure we have the capacity to capture market share in a challenging environment.
Mark Behl. Executive Vice President and COO of Froedtert & The Medical College of Wisconsin (Milwaukee): Our health system has really been focusing on a few key areas. First, continuing to transform the delivery of care in all areas across the healthcare continuum. We simply cannot afford to deliver services in the same way. Reimagining the teams we have in terms of skillset, the use of technology, and how we can attract, retain, and develop the workforce of the future. If we can reduce the need for hard-to-recruit positions, we must look at it.
Secondly, we are focusing on how we can reduce the use of agency and premium pay. This requires thoughtful reviews of programs and services, and where some strategies may not be working or have run their course, which leads to reducing or sometimes having to close particular services. Finally, we are being incredibly diligent throughout our planning to ensure that we are not adding new costs to the systems. This has led to some projects being put on hold. In contrast, we also are searching for short-term projects with higher ROI to help bridge the needs of the system here for the remainder of this year and next.
Tracey Lewis Taylor. Chief Operating Officer of Stanford Health Care - Tri-Valley (Pleasanton, Calif.): Despite rising costs and shrinking margins, Stanford Health Care Tri-Valley remains focused on quality, outcomes, and value. In order to reduce cost while maintaining quality, we leverage external benchmark data to identify key areas where our costs are outpacing those in our comparative peer group. Two key strategies to reduce these costs include a focus on talent pipelines and optimization of supply chain and pharmaceutical drug pricing and utilization.
Building our internal pipeline has allowed us to focus on formal nursing recruitment and retention strategies aimed at reducing the reliance on higher-cost agency nurses. One tactic we launched was the development of a student nurse-to-nurse residency pathway. This pipeline enhances the clinical competencies and confidence of new grads and, through formal mentorship, has improved the retention rates among newly hired employees. In addition to the nurse residency pathway, transition to practice programs have been implemented to help build skills and competencies among med/surg nurses so that they can effectively transition into harder-to-fill roles within critical care, interventional/surgical services and labor and delivery.
In addition to labor costs, we are strategically focused on our non-labor supply costs and have utilized partner organizations to help us identify our overall cost and spend index as compared to our local/regional and national peer groups. To improve efficiency in our spend, we utilize robust analytics tools to identify prioritized areas for contract negotiations, rebates, and supply chain/pharmacy conversions. A component of this work includes our Cost Savings Reinvestment Program, which was designed to engage physicians in identifying and leading cost-reduction strategies while maintaining or enhancing the quality of care provided to hospital patients.
These two strategies noted above are part of a broader approach to create visibility and transparency about our costs, quality and efficiency metrics and create the accountability structures and tactics that will drive short and long-term organizational results.
Anuj Vohra, DO. Chair and Medical Director of the Department of Emergency Medicine of Charlotte Hungerford Hospital (Torrington, Conn.): Three things we're doing to reduce costs are reducing and attempting to eliminate the use of locums/travelers, reducing nonemergent inpatient MRIs and having pharmacy coordination to reduce waste and improve utilization
Sarah Poncelet. Division Chair, Strategy Development of Mayo Clinic (Rochester, Minn.): Our system is seeking to find automation solutions across routine tasks to ensure everyone is working at their highest levels and ensure high productivity balanced with outcomes, safety and experience. Our supply chain and finance are forecasting inflation cost increases and/or decreases and negotiating lower costs than during the pandemic. Investments are being considered for both opportunities as well as reassessing capital allocation.
Reshma Gupta, MD. Chief, Population Health and Accountable Care of UC Davis Health (Sacramento, Calif.): We, like many health systems across the country, are facing financial strain after the covid pandemic. We have focused our efforts in delivering more efficient care by expanding our care at-home programs to deliver more care at patient's homes. These efforts include developing workflows to expand acute, subacute, and chronic care at home as clinically appropriate.
Our IT and operational leadership have developed new contracts and workflows to lead this work. Other analyses have been done to see where opportunities lie to shift the site of care and move to lower-cost medications both for our patients and the system. We have only increased our standards around quality and equity as these programs roll out. In the world of population health and accountable care, this redesign has been long in coming and allows for improved quality, experience, and service reach to our community.
Ravi K. Bashyal, MD. Clinical Assistant Professor of Orthopaedic Surgery of NorthShore Orthopaedic and Spine Institute (Chicago): One of the keys to cost containment is standardization. This is very complex in a surgical environment where surgeon preference/comfort/philosophy makes it difficult to standardize all components. The key is to find areas where there is consensus among surgeons and staff/colleagues on the ability to standardize - e.g., drapes/irrigation/gloves, etc., as opposed to trying to standardize something like an implant choice carte blanche. Taking a balanced and measured approach to standardization while respecting surgeon choice on critical items is a good way to work on cost containment.
Michael Archuleta. CIO of Mt. San Rafael Hospital (Trinidad, Colo.): At our healthcare organization, we recognize the need to reduce costs while maintaining the highest standards of care. To achieve this goal, we are taking several strategic steps, including:
1. Streamlining our operations: We are continuously evaluating our workflows and processes to identify opportunities for improvement and eliminate any inefficiencies. By optimizing our operations, we can reduce waste and lower our costs.
2. Investing in technology: We believe that technology can play a key role in improving patient outcomes and reducing costs. That's why we are investing in digital tools and solutions that can automate routine tasks, improve care coordination, and enhance patient engagement.
3. Collaborating with partners: We are committed to working with our partners across the healthcare ecosystem to drive efficiencies and reduce costs. By sharing resources and collaborating with payers, providers, and other stakeholders, we can develop innovative payment models and improve the overall quality of care for our patients.
Kristoffer Popovitch. Senior Director, Operations of Hartford Healthcare (Conn.), Central Region: Hartford Healthcare has put a tremendous focus on innovation over the last several years, which has allowed us to navigate the effects of the COVID-19 pandemic. Part of being innovative means looking ahead and being proactive in how we react to our ever-changing world. Two of the biggest hurdles we've had to overcome include our workforce shortages and finances, which have affected healthcare across the country. Yes, we are all in the same situation, but it's how we've reacted to that situation that continues to set Hartford HealthCare apart from all the others.
We believe that the key to success is having a strong team of colleagues who feel supported, accepted and respected. This is the foundation we've built at all seven of our acute care centers, medical group locations and the roughly 400 outpatient centers across Connecticut. Senior leaders have carefully crafted a structure within the organization that has helped make Hartford HealthCare an attractive place for people to work. Those efforts have paid off, as we have strong employee engagement – with a focus on retaining our colleagues.
However, we know that workforce shortages have become all too common and we've had to think outside the box to make sure we can add to our incredible team of colleagues. We've developed new job roles to help maintain our high level of care, enhanced relationships with the communities we serve and partnered with high schools and colleges to ensure the next generation of workers to a career in healthcare. These measures have netted us significant results and made the healthcare we provide our patients seamless.
In addition to building our workforce, it's important to note we have to be mindful of our revenue and expenses. Each level of the management team works carefully with the front-line staff to regularly evaluate our budgets and look for opportunities to reduce overall costs for our patients and the organization, which includes our annual management action plans. Cost-saving measures are never easy, especially in a post-pandemic world, but we are doing what is necessary to care for our patients and ensure our success – understanding the important role we play to countless people seven days a week, 365 days a year.
Being good stewards of our finances and paying close attention to the recruitment and positive work environment of our colleagues has given us the tools we need as we pivot from what healthcare used to be and look ahead to the future.
Scott Dimmick. Senior Vice President, Chief Human Resources Officer of Lakeland Regional Health (Fla.): To reduce costs, we have decreased the use of contract labor use through improved staffing levels and improved recruitment and retention activities and have decreased the rates paid to the small amount of remaining temporary agency personnel since we have found that the common reference to "travelers" when describing temporary agency personnel is a misnomer as the majority of those individuals actually live in our surrounding communities and are not incurring major inconveniences to travel to the worksite.
Additionally, we have examined other purchased services and contracted services and have been able to reduce or eliminate some of those services and/or reduce the negotiated costs for those services. Collectively, these initiatives have continued to contribute to cost containment objectives.
Kerry Mackey, DBA. Vice President of Hospital Operations, Women and Children’s Services, at NYU Langone Health (New York), NYU Langone Hospital – Long Island: Several things can be done to reduce costs:
1. Workforce engagement to prevent turnover and improve outcomes (e.g., nursing reconstructing through a weekend incentive program, educational opportunities, reduce/no nursing floating to over units)
2. Improving care coordination to close care gaps and reduce readmissions (e.g., calling all patients with high-risk diagnoses weekly for 30 days post-discharge and follow-up calls to patients discharged from the emergency department)
3. Re-evaluate supply costs and contractual service agreements
Ron Amodeo. Chief Strategy Officer of UC Davis Health (Sacramento, Calif.): We have a few things we're doing:
Full cycle recruitment: This project will address the process and tool gaps identified in 2021 through the implementation of a holistic end-to-end Full Cycle Recruitment platform. This platform will meet current hiring and anticipated growth needs. Cost reduction is expected through automation and optimization of processes. Revenue generation is expected to improve as well through productive hours and a reduction in vacancies.
Capital improvements process mapping initiative: The goals of this process mapping initiative are to identify ways to move current processes and their associated milestones to the next phase across units/divisions and to efficiently speed up the completion of deliverables without sacrificing controls. To this purpose, the project team will consider opportunities aimed at improving project timelines, identification of operational challenges/issues early for quick resolution, and outlining timelines, roles and responsibilities across the project teams and stakeholders involved. Cost reduction is expected through the reduction in lead times and completion of projects.
James G. Terwilliger. Senior Vice President and Chief Operating Officer of Virginia Mason Franciscan Health (Seattle): Last year was the worst financial year for hospitals and healthcare systems since the beginning of the pandemic. It is expected the financial strain and frontline labor shortages within the healthcare industry will continue, so the road to recovery will be a multi-year, uphill climb.
At Virginia Mason Franciscan Health (VMFH), it is imperative for our leaders to be innovative in how we meet the changing needs of our patients and team members. The Virginia Mason Production System (VMPS) has been integral to helping us innovate and reduce costs by prioritizing patient-centric care, reducing waste, eliminating errors and inefficiencies, and improving experiences for both patients and team members. We have worked diligently to reduce expenses in supplies, vendor contracts, overtime, productivity, contract labor and length of stay.
VMFH continues to leverage technology to address rising costs and staffing challenges facing health systems today. Our Mission Control Command Center has successfully integrated technology solutions like AI and predictive analytics to manage staffing and resources system-wide. VMFH is also launching an Enhanced Collaborative Care Program that integrates virtual nurses with teams in the hospital to provide immediate patient care at the touch of a button. We are confident this will help us provide efficient care while supporting, retaining and building our workforce.
Angelo Milazzo, MD. Vice Chair of Practice and Clinical Affairs, Department, Pediatrics; Professor of Pediatrics, Division of Pediatric Cardiology of Duke Health (Durham, N.C.): As a cost reduction or value enhancement strategy, we are working to maximize the utility of our fixed resources. For example, we are redesigning clinical schedules and office space templates so that our outpatient facilities can be used both during and outside of traditional hours (including extended hours on weekdays as well as sessions on the weekend for both primary and specialty care services). This broadens our access, is a satisfier for patients and families, and creates a better match between capacity and demand.
Joanne C. Skaggs, MD. Inpatient Medical Director, Adult Division of OU Health (Oklahoma): I always prefer to look at things positively, so rather than reduction, I like to look at how we can increase growth. OU Health COO Jonathan Curtright believes in saying "yes." By saying yes, we have actually seen an increase in our inpatient volumes. Our development and deployment of the inpatient collaborative care model on the adult side have allowed us to innovatively utilize interdisciplinary roles to provide patient-centered care. This has ultimately led to decreased contract labor spend, decreased turnover, and provided more FTEs at a lower cost. The cost per patient day on the units where this has been implemented has decreased significantly.
Deana Sievert, DNP, MSN, RN. Chief Nursing Officer of University Hospital and Ross Heart Hospital of The Ohio State University Wexner Medical Center (Columbus): Similar to most organizations, we are working on stabilizing our workforce as best as possible. We have specifically capitalized on recruiting temporary staff to full-time staff, spending time reaching out to employees who left in the last three years and focusing on our culture around wellbeing.
Additionally, the length of stay work has been critical to our financial success. We have worked hard to get everyone moving in the same direction, having a full understanding of the imperatives and then pushing forward and holding people accountable when needed while, of course, using a just culture approach.
J.J. Kuczynski, PT, DPT. Senior Consultant, Team Performance and Execution of The Ohio State University Wexner Medical Center (Columbus): In response to declining inpatient volumes and high inflation, our system has emphasized care reliability through spending and utilization variation reduction across key areas such as lab, imaging, supply, and drug, to name a few.
Additionally, there have been significant efforts toward optimizing patient flow throughout the system to ensure timely and efficient access at the appropriate care site. While the challenging financial realities are significant and need to be acknowledged, substantial emphasis and attention should be placed on the patient-centered experience and commitment to quality.
Adrienne Moore, DrPH. Vice President of Revenue Cycle of Banner Health (Phoenix): Thoughtful stewardship of our financial resources continues to be a priority for Banner. This requires accountability to our financial targets, but it also becomes a leverage point for innovation, automation and optimization of the tools we already have. We are focused heavily on the recruitment and retention of employees to reduce our dependence on contract labor.
We have especially prioritized supporting the well-being of our frontline clinical staff through on-site counselors, respite areas and more, which have improved burnout levels and reduced dependency on contract labor. A focus on quality is also a theme – we know that when we improve quality measures, we reduce costs for our organization as a whole. We assess our real estate portfolio on an ongoing basis and always look for opportunities to deploy the most effective financing strategies.
We also recognize that financial health is not only about cutting costs. We continue to invest in areas where we want to grow strategically, like adding community-based locations where our patients can receive care close to home and increasing access to telehealth and other digital health innovations.
Francesca Varallo Sims, PsyD. Director of Education and Training of Baptist Behavioral Health: To reduce costs this year, we are leveraging advanced practice providers, including nurse practitioner fellows and other behavioral health trainees, to address staffing shortages across the department. Implementation of our clinical training program increases provider retention in areas of need by hiring APPs at the completion of their fellowship. This train and retain staffing methodology results in recruiting and human resources cost-savings for the system at large. Finally, investing in the fellow's continuing education serves to improve employee satisfaction, as well as cultivate their connection and engagement with the hospital, leading to reduced turnover.
Jeffrey P. Gold, MD. Chancellor of University of Nebraska Medical Center (Omaha): (1) Maintaining the highest level of quality, safety and patient experience (2) Optimizing staff recruitment and retention policies and practices (3) Strengthening real-time data-driven decision-making.
Kristina Wertz. Assistant Vice President of Revenue Operations of ThedaCare (Neenah, Wis.): We realized that focusing solely on cost reduction was not enough to achieve sustainable financial success, so we've heightened focus on capturing all owed revenue in an efficient way. We continue to prioritize initiatives to prevent denials, ensure accurate capture of the complexity of services rendered, and improve utilization management to help us maintain a strong financial position while providing the best care possible for our patients. Shifting the perception of the revenue cycle from a cost center to a value driver has helped us keep care quality at the forefront of everything we do.
Nike Onifade, MS, FACHE. Division Vice President, Oncology Service Line, Texas Division of CommonSpirit Health (Chicago); Vice President, Dan L Duncan Comprehensive Cancer Center of Baylor St. Luke’s Medical Center (Houston): Given the post-pandemic shift in margins for most healthcare organizations, it has been critical for us to tightly control expenses while still investing in high-priority strategic projects to maximize our revenue streams and thus our financial stability. Our leaders at all levels, from front-line supervisors to senior executives, are all expected to be good stewards of our financial resources. This culture encourages real-time engagement in departmental performance, and that focus is helping our system better control our labor expenses, including those related to contract staff, overtime, and turnover.
Secondly, one of the many benefits of working for an organization like CommonSpirit Health is the ability to collaborate with the best and brightest across the nation, and what works well in one market can be used to drive success in another. For example, the Dan L Duncan Comprehensive Cancer Center at Baylor St. Luke’s Medical Center has been working with other cancer centers across CommonSpirit to share best practices and identify opportunities to reduce costs specific to supply chain, pharmacy, equipment, and software, all without impacting the high-quality and compassionate cancer care we provide for our patients.
Cristy P. Page, MD, MPH. Executive Dean of UNC School of Medicine; Chief Academic Officer of UNC Health (Chapel Hill, N.C.): We've implemented a number of measures over the past year to reduce expenses. One measure has been to look very closely at our capital plans. North Carolina is a rapidly growing state and we need to continue to expand the care and services we provide. However, given the current financial challenges, we are now looking very carefully at where we strategically place our investments in order to meet these needs without over-extending ourselves financially. We are also carefully considering new hires to ensure recruits align with our strategy and clinical needs.
Daniel Feinberg, MD. Chief Medical Officer of Pennsylvania Hospital (Philadelphia): Although my hospital did not experience declining inpatient volumes, we did see higher volumes of emergency room patients and resultant increased numbers of medical patients. Our hospital and health system are most focused on the reduction of inpatient length of stay, which allows for access to additional patients being admitted for care.
In addition, labor pressures have been significant disciplines, resulting in high rates of turnover and the use of premium labor. Our colleagues are our most valuable asset and define who we are as a hospital and health system. We have focused on the recruitment and retention of our best colleagues, alleviating our dependence on using overtime and agency staffing. Since the turnover of staff, physicians and advanced practice providers is very costly, we have been very attentive to enhancing the joy of practicing in our hospital and health system.