Featured Guest: Brett McClain

What he does:  Brett is the Executive Vice President and Chief Operating Officer for Sharp HealthCare in California.  At Sharp he has direct accountability and oversight for the daily and strategic operations of Sharp's four acute care and three specialty hospitals, three medical groups, ambulatory and clinical service lines, and facilities management and development.  His career spans nearly 30 years of health care management experience in a variety of operational, consulting, and executive leadership roles overseeing various hospital and medical clinic operations where he has been instrumental in leading growth strategies, large-scale capital investments, clinical integration and service area optimization, patient safety and performance improvement, and service line development.

On risk:  "There's a lot of consistency with risk in health care over the years.  As time has gone on the risks have changed and evolved and been added to as well. One of the lessons through COVID has certainly been the very real chance and issue and risk of multiple things happening at the same time, not just one big event. I think what's evolved around risk is the recognition that we need to have processes and people and policies and practice in place in order to deal with multiple catastrophes or multiple risks at the same time that can stress the organization in ways that probably haven't been experienced before … A flavor of some of the things we're looking at now at the top of the list is absolutely cybersecurity. It is something that continues to be critical in nature for all of us in health care and something that we cannot take our eye off any single day. The resources we've had to put into that, the people and the processes and the systems in order to assure that we are safe. We get hits every day, every single day, someone's trying to bad actor out there, trying to make something happen.  Here in California we put the legislative risk pretty high up. It's not just on a state basis, but on a state basis here in California we have a very active legislature, and we put a lot of time and energy to monitor the things that they're working on. Make sure that we're taking a look at the impact so that we can communicate and educate our legislators. We spend a lot of time doing that … I've never seen something like this (workforce) in the past. The toll in terms of the physical, as well as mental toll, under all of us and folks just deciding this is not something I want to do any longer and changing the whole workforce perspective of working within health care. That is a massive risk for the entire industry. It's probably the one thing that I'm most concerned about, and most challenged by, about how do we respond to that and the moment so that we can assure that we have the workforce of the future, not just for today"

Transcript

Scott Nelson  0:01  
Welcome to The Risky Health Care Business Podcast, where we help you prepare for the future by sharing stories, insights, and skills from expert voices in and around the United States health care world with a mission to inform, educate, and help health care organizations and individuals, ranging from one doctor practices to large integrated systems and organizations throughout the dental, medical, and veterinary health care industry with risk, while hopefully having some fun along the way. I'm your host, Scott Nelson, a guy that grew up in Ohio and has been working all over the United States during my 20 plus year and counting career in the health care industry, with a commitment to accelerating health care performance through creativity, not just productivity. Let's dive in.

The National Oceanic and Atmospheric Administration's National Centers for Environmental Information has published research that shows the US has sustained 373 weather and climate disasters since 1980 where overall damages or costs reached or exceeded $1 billion, including CPI adjustment to 2023. The total cost of these 373 events exceeds $2.645 trillion. The first three years of this current decade - 2020 through 2029 - is on pace to increase from the previous decade - 2010 through 2019 - in number of events and cost. 

Imagine a scenario of being in an area where weather and climate related adverse events like wildfires, tornadoes, winter storms, hurricanes, or flooding are prevalent. Now keep going with that scenario and add on top of it happening at the same time a staff that feels spread thin with staff departures, or a technology issue that has abruptly halted computer services like a cyber attack. A natural disaster might be thought of as a low probability scenario, maybe depending on geography, but workforce departures can unexpectedly happen at any time. Cyberattacks continue to increase. Financial and legal issues should always be considered. Is your health care business prepared and ready to absorb and manage one adverse event? Would it survive two happening at the same time? 

Many people and organizations will conduct scenario planning and exercises with one adverse shock event if any are done at all. Earlier this year, today's guest along with his organization had to manage a real life event that involved staffing issues at the same time facing Hurricane Hilary at a system facility in Southern California. 

Today I'm speaking with Brett McLain about risk in health care, including facing multiple simultaneous adverse events, risk types and variations, activities to help plan and prepare for risk events, and more. Brett is the Executive Vice President and Chief Operating Officer for Sharp HealthCare in California. At Sharp he has direct accountability and oversight for the daily and strategic operations of Sharp's four acute care and three specialty hospitals, three medical groups, ambulatory and clinical service lines, and facilities management and development. His career spans nearly 30 years of health care management experience in a variety of operational, consulting, and executive leadership roles overseeing various hospital and medical clinic operations where he has been instrumental in leading growth strategies, large-scale capital investments, clinical integration and service area optimization, patient safety and performance improvement, and service line development. 

Let's talk with Brett about risk in health care. 

Brett, welcome to the show. 

Brett McClain  3:18  
Hey, thanks, Scott. 

Scott Nelson  3:19  
Before we begin talking about risk in health care, let's go back to the beginning. How did you get into health care and where you are today? 

Brett McClain  3:25  
Well, not really purposeful it kind of just happened. I got hired by a very small boutique consulting firm back in the late 80s after working for a national trucking company, actually, in a management training program, and they focused largely in health care, wanted to also get involved in some manufacturing and logistics kind of supply chain. And so I got hired at a very young age and was brought into this company, it was called West Hudson, a fantastic organization. And ended up really while we did some non health care ended up really focusing mostly on health care, probably 90% of the work was in health care. So spent about 11 or 12 years there working in all sorts of different health care organizations, small, large systems, academic, non community, etc. And got to travel the country, got to meet my wife at a project, and and here we are, you know, almost 30 years later. Just an incredible way to learn health care, to kind of see different models and different markets as well. Ended up being a partner in that organization. And then we sold the company to, when Baxter split into two companies, became Baxter and Allegiance and then ultimately was purchased by Cardinal Health. And then decided to not be on the road so much with two brand new children, and so I left and actually went to work for a client.

Scott Nelson  4:58  
At Sharp you have direct to accountability and oversight for the daily and strategic operations of Sharp's four acute care and three specialty hospitals, three medical groups, ambulatory and clinical service lines, and facilities management and development. Is there a typical day at work for you? If that's possible, what does it look like?

Brett McClain  5:16  
Typically untypical, I guess, right? You know, seriously, I think those of us that are, in my mind fortunate enough to be in operations, and to work with the incredible folks who make things tick every day, really, you never really know what's going to happen on a daily basis. It's part of the challenge, but it's also part for me, part of the excitement. I love dealing with the, you know, the stuff that are challenges for us and working through those and then also being able to deal in the, in the incredible successes and celebrations that we have on a daily basis. So, you know, the the, at the end of the day, we're trying to move the needle in terms of our strategy and our performance and our impact here in San Diego to the community, we are the largest provider of health care in the community of San Diego. And so just trying to move that along and deal with the bumps in the road. And sometimes there's, you know, three year long bumps, like COVID. But there are certainly daily issues that happen that you have to react to, luckily have an incredible team that is capable of handling all of that as those issues arise. But not not really a typical day.

Scott Nelson  6:24  
Well, with your point about never knowing what's going to happen each day, I'd like to start our conversation by getting your thoughts on how you think about risk in health care. You've been involved in many initiatives at health care organizations across the US in a variety of roles. How do you think about risk in health care?

Brett McClain  6:38  
Well, I think, you know, I think there's a lot of consistency with risk in health care over the years, you know, You're always trying to lower the risk for our patients and for our staff. Just in the delivery of health, health care, we're dealing with very, you know, highly technological, you know, practices and equipment, and pharmaceuticals, and all of that. And that's been the case forever, you know, we'd learn new things, and we learned new ways in which to, to deal with those risks. But that's been an ongoing kind of part of how we manage the delivery of care. I do think as time has gone on, the risks have changed and evolved and been added to as well. And I would say probably one of the lessons through COVID has certainly been the very real chance and issue and risk of multiple things happening at the same time, not just one big event. And here in California, we have all sorts of natural issues that can happen, as well as you know, the non-natural things that can happen within our industry as well. And so I think what's evolved around risk for us is the recognition that we need to have processes and people and practices and policies and practice in place in order to deal with unfortunately, multiple catastrophes, sometimes, or multiple risks at the same time, that can stress the organization in ways that probably haven't been experienced before. So, you know, trying to take the lessons that we've learned over the last three years and put that into practice has really helped us evolve into how we as an organization think about risk as well, not just kind of on those individuals certain, you know, circumstances that might happen.

Scott Nelson  8:34  
Well, and you mentioned various places where where risk can take place and in your experiences at Sharp over the last few years, thinking about patients and staff and beyond, why do you feel it's important to think about risk and be actively planning and preparing for it? What can happen in those risk events? Or what happened during COVID, through your experiences, that affects those patients and staff in the overall organization?

Brett McClain  9:00  
Yeah, you know, the, during the pandemic itself, you know, we all were dealing with kind of the in the moment issues of not knowing exactly what this thing was. It's hard to even put our mind around that about what where that was at three to four years ago. But we didn't really know and you know, the amount of work and energy and time and costs and resources we had to put into being able to protect both our staff, who are going into care for people with a largely unknown, you know, enemy here, and also keeping family members and other patients safe as well. You know, so it just, it was that certainly in the moment and having to deal with that, very fortunate here. I started literally on the day, pretty much everything closed in California, here at Sharp on the middle of March of 2020. But very fortunate that we had a highly engaged group, we call it the Highly Infectious Disease Group, and it had been used in other circumstances in the past - highly engaged. And we actually had a daily, for over two years, daily call with about 170 leaders throughout the entire system. This made sure that we all had the most current and up to date knowledge of what was going on. But also importantly, as things evolved, changed what we were doing on a daily basis at a system level, as opposed to just at an individual facility level. So that, you know, that was very helpful. Now, I you know, I think the, the real impact that, you know, we had no idea what's coming was certainly, you know, the impact to our workforce, and I have never seen, been in health care for 30 years, I've never seen something like this, in the past, just the the toll in terms of the just the physical, as well as kind of mental toll, under all of us and folks that just deciding this is not something I want to do any longer. And just changing the whole workforce perspective of working within health care. And we that is a massive risk for the entire industry, it's probably the one thing that I'm most concerned about and most challenged by, about how do we respond to that, and the moment so that we can assure that we have, you know, the workforce of the future, not just for today. So this has this has really challenged our system, I think, allowed us to maybe think things a little bit differently, which is, which is always good. But I think we're still in it, you know, we're still in that evolution of the health care worker right now.

Scott Nelson  11:37  
For a long time, health care viewed risk as subjects like compliance, so coding and billing for example, quality and safety, such as errors and sentinel events, complicated legal issues, like patient lawsuits. Today, technology is a growing consideration. On Sharp's website landing page, there's a box and a "Get Started" button for virtual urgent care. Your work crosses the organization and can expand outside so where is risk in health care for you? What are the areas of risk in health care that are or should be of concern, should be watched and monitored? You had mentioned workforce and staff a little bit as well. Are there other areas you focus on as well?

Brett McClain  12:12  
Yeah, certainly. And you hit the ones that I think will usually be on that list. We have a pretty rigorous and meaningful process that we go through on an annual basis to look at what the risks are to the organization. And then the senior level members of our team will go through a process to categorize those as well as to rank them in terms of importance, and we look at them from in kind of an inherent risk score, if you will, on just inherently this the category. And then we look at the residual risk at the end of the day, which takes into consideration, yeah, you got this inherent risk, but what are your business practices to be able to mitigate those risks, and so then, therefore, what is the residual risk? And we look at all of that in, in every single year go through, again, a pretty detailed process. And so just to give you a flavor of some of the things we're we're looking at now, which have not really changed over the last probably two to three years, some of the order has. At the top of the list is absolutely cybersecurity. It is something that continues to be critical in nature for all of us in health care, and, obviously a sense of frustration for those of us in this work, but also something that we cannot take our eye off any single day. So you know, just the resources we've had to put into that, that people and the processes and the systems in order to assure that we are safe. We get hits every day, right every single day, someone's trying to bad actors out there trying to trying to make something happen. So that is something that is way at the top of the list that has our focus. Again, we talked about workforce, but we also focus as a risk on our provider alignment, right, our physicians and our community providers out there as they are going through kind of changes and adaptions from that they're having to make through from the pandemic as well. How do we assure that we're aligned with them and providing a an attractive place to for them to practice medicine. And then here in California, unfortunately, we put the legislative risk pretty high up. It's not just on a state basis. There are certainly national pay practices and just the challenges that we're all having right now and Medicare and Medicare Advantage as well. But on a state basis, here in California, we have a very active legislature, and we put a lot of time and energy to monitor the things that they're working on. Make sure that we're taking a look at the impact to Sharp specifically so that we can communicate and educate to our legislators, we spend a lot of time doing that, you know. Every couple of years you've got a big percentage of brand new folks in the legislature that may not know a lot about health care. So we spend a lot of time educating. But there's decisions that are made. Now, we just had one here in California where the governor signed a bill that is enacting a minimum wage for health care workers over the next couple of years. And so we have to work on how we're going to pay for that. There's no additional funding for that, we certainly support, strongly, the need for our health care workers to earn a reasonable living. Especially here in a very high cost area and state. We just need a plan and a process and kind of a runway to get there. So we're working through that as well. And there's, you know, obviously other things on the legislative slate regarding seismic building restrictions and things like that, that we have to work through. So just a couple other examples that we have and in addition to the ones that that you mentioned there. And we end up with usually about, you know, 10/12 top categories that we focus on in risk.

Scott Nelson  12:27  
And when you are looking at your categories and the rankings, and when you talk about cyber and provider alignment and legislative and some of the other risk areas, I'm sure that those are all very different when you look at them individually. Having multiple locations and multiple departments that span a geographic region, do you see risk variations among those different units or locations or organizations or departments within the organization?

Brett McClain  16:35  
You know, that's a great question in particular for San Diego. I'm going to be honest, before I came to San Diego, I knew it as a vacation spot. And have certainly learned over the last four years here that San Diego is also a very, very diverse mix of communities and cultures and kind of individual, you know, nuances based on the location and the geography. Having we have a one of our acute care hospitals, Chula Vista, is only about four miles north of the Mexico border. And we have certainly seen through some of the federal legislative challenges around immigration and Title 42 here in California of the impact of immigrants coming across the border. And some of those folks have have traveled by foot for months and months through Central and South Mexico through the northern part of Mexico coming across the border in Tijuana. And at that point, many need some health care and or are pregnant or, you know, break an ankle, etc. So there's a lots and lots of impact on those community resources, including our very substantial presence with our Chula Vista hospital down there, that is different than something that you might see in, you know, more northern parts of San Diego. We also have clinics down there as well. And they have a you know, they provide an impact for that patient population as well. So yeah, there are some, certainly some differences. We have an East County Hospital, the busiest emergency room in all of San Diego, Sharp Grossmont, and they are really the only substantial hospital just due west from the entire Imperial County. So that has sometimes a large impact from difficult issues and, and emergency room visits from just east there as well. So yeah, definitely some differences here and something that I hadn't really thought through before kind of being in the middle of it.

Scott Nelson  18:48  
Going back to the end of last year, and during this year, there has been reporting about health care organizations, closing facilities, departments or ending services to address things like finances and staffing. Finances and staff could be considered as examples of risk. From a broad view over medical care, thinking about closures or other examples you'd mentioned, what if multiple things happen at one time, what can be done to strengthen and manage risk and decrease vulnerabilities for a health care organization?

Brett McClain  19:15  
So yeah, you're I mean, you're right, Scott, the financial impact and, and all of that is absolutely one of our risk categories. We have a incredible capital plan ahead of us a couple billion with a B dollars over the next number of years here to be able to expand in the county to provide the services that the San Diego community is used to. We need to build again seismically compliant facilities on our hospital campuses, and in order to do that we have to be able to fund it. And so we go through a again a very structured, organized, kind of best practice process on a five year planning. And we do that it's a rolling plan every single year and determine really what our financial outcomes need to be where we need to enact improvement plans. We implemented and started a Office of Transformation over the last year and a half or so to be able to implement system wide changes on large initiatives to provide savings for the organization. So that happens kind of in parallel with all of the other work that we're doing, in order to make sure that we can continue to do the things that we have committed to and our Board has supported us to do. So it is right at the at the front of the risks for us to be able to make sure that we are managing the books in order to continue to invest. Very fortunate that we have a strong balance sheet, very fortunate of our success to date. And it's imperative that we maintain that.

Scott Nelson  20:56  
I'll start this next question with a personal note. You and I have known each other for years now because you were my boss when we were at Dignity Health in Arizona. I'd like to get your thoughts on risk and resources. I'm gonna go out on a limb here because of having worked for you, and still connected and friends with individuals that worked for you, I'm going to start by saying people are on the list, not just your direct reports, but the people throughout an organization are important to you. What resources have you found helpful or critical in your work managing risk?

Brett McClain  21:24  
Well, I think that if you are not, if you are not connected with the frontline folks that are doing the hard work that we do on a daily basis, and that they you know, can't understand the why for some of the challenges or changes or cost saving measures, etc, then you're just sunk. I mean, it is imperative that we connect our our frontline staff to the why sometimes the you know, what's happening is difficult if we, you know, end up having to close a program. We had to make a very tough decision in the last few months to close our home health agency in the system and to partner with others on the outside. It's always the hardest thing we do. It is, you know, to stand in front of a group of folks and let them know that we just can't afford that business line anymore. It is the toughest thing that we any of us as leaders can do. And you just have to continue to connect back to the why, right, the why of Sharp being San Diego's health care leader, and that our mission is to continue to provide that care. So I just have had always a very transparent, hopefully, approach and style, and have always been open to questions and criticisms and kind of pushing the envelope. And we've continued that we have a very open, direct communication to all of our employees. We meet with them, very, very often. I will say it's a little bit of a benefit of COVID, of everybody kind of getting used to this whole virtual thing, and our employee forums, you know, you set a time for an employee forum and, you know, a significant portion of the staff can never come even if you provide it at different times, it just doesn't necessarily work out. Well, in virtual, you're able to have much more of an impact. And we've seen some times, you know, double the amount of employees showing up for some of our forums when they're virtual. Now we're starting to mix them back up into in person and virtual. So I think it's you gotta you have to rely on your folks. We're here to serve them, and to hopefully make their lives a little bit easier, so that they can do the real work.

Scott Nelson  23:35  
And you'd mentioned some things about connecting to those folks and doing that through one of the lessons learned, everybody's been able to take on more different methods or ways to communicate, you know, virtually and in person. When you look at engaging with those groups, is it a simple just message and there's rounding and town halls? Do you get out there and meet with him individually, spend some time out there? I'm assuming you, you and your team, you guys are very busy, and you have a large organization you're getting with. Virtual and in person, you know, trying to connect with groups like that, sometimes can present a challenge and be impersonal when you're trying to create that kind of a message.

Brett McClain  24:13  
I think it's all the above I think it is, it's all the above, it's about being present in person at times. I love rounding it's the thing I miss the most about not being in a hospital anymore. I love the ability to you know, kind of run up and and do a quick, quick tour quick round, connect with folks that are doing that hard work. It's where I get my energy back when I get to see folks do that. I think that it's about being being able to do all of those. Not, you know, hear everybody say, you know, are we getting back to the new normal or is this the, I think the new normal is the mix. Is the ability to meet people on their terms in a lot of different ways. I think personally the most important part of it is consistency. It's not a flavor of the month that we're just not going to do this, you know, this forum this way for this quarter in that way, et cetera. It is something that you commit to consistently. Part of The Sharp Experience, which is really our entire culture here, but part of The Sharp Experience is what we call leadership development. And since the year 2000, for every single quarter, we have brought together all of our leaders. And so that's about 1,800 people in the organization. Prior to COVID, it was done all in person, was over a couple of different days, and there were topics in there about, again, leadership development, these are all from kind of that lead supervisor level all the way up to our vice presidents. And during COVID we switched it to virtual. And so I said that we've done it every quarter, we've done that every single quarter, including through COVID, have not missed one. And that commitment, I think, to our leaders in particular, that they know that we will continue to come back. And yes, we do some updating of you know, the performance of the organization, where is our scorecard, but we also take issues in the moment as well and respond and react to kind of what our what our staff are dealing with. And I'll tell you in the middle of January of 2022, when we were in that surge at that time, we could tell that the organization was just really challenged and hurting and dealing with stress in ways never before. And we two days before that, that huge leadership development sessions, we switched the whole topic of the session to we called it Stress First Aid. And we worked with our behavioral health hospital and those leaders to develop a process to allow our frontline leaders have a place in which they could get help if they needed it, group work sessions, and it's something that continues on today. And it just, I think a recognition of the staffs incredible work. So I think it's that just you know, we can change the how and how we connect with folks. It's really mostly about being consistent, and kind of sticking to our word that we're going to continue to be connected.

Scott Nelson  27:12  
Sharp has the annual risk process, it recently went through an enterprise risk management project. What are your thoughts before and after since going through that experience? What was that process like?

Brett McClain  27:24  
I think, you know, I think it's for the senior team, so we have a group in the organization that we call executive steering, it's about the 15 or so senior vice presidents, and they in between them they run the entire organization, all the all the operation, the hospitals, the medical groups, all the system services, and you know, finance, marketing, legal are and then we have our health plan, and just all the different components of the organization. I think it's you know, it's a great grounding time for all of us to assure that we're all on the same page. We individually actually rank and then we come together to work through what we think is kind of the final picture should be, because then we present that to our Board. And we have a subcommittee of our Board that is incredibly connected and active with us in identifying, you know, other risks as well. We actually go through in details with each one of them. And the individual subcommittees of the Board will approve those risk category rankings and then it goes to the full Board for approval. It's it's a really kind of a annual unifying process to make sure we're all on the same page as to what's going to eat our lunch, you know, right now, what are the challenges in front of us? And how, you know, how can we work together? Because I'm not an IT person right but I have obviously a significant stake in any kind of cyber activity issue. So we've, you know, just work very closely together, and it's kind of just that one time of year where we, we all can focus on those issues together.

Scott Nelson  29:01  
Those processes can sometimes be a big undertaking, do you see where there can be challenges to that? I always have an analogy of turning the large ship for larger organizations or resource availability for smaller health care organizations. Sharp is a sizable organization, but if an organization or practice, wanted to be proactive, but not take on that type of a solution, what would you recommend someone prioritize and implement? Like, are there one, two or three important actions that a doctor or health care organization can and should be doing to decrease their vulnerabilities and to strengthen and manage risk?

Brett McClain  29:34  
Yeah, I think I mean, I think you, you just got to get a couple in a smaller organization, maybe stand alone, just gotta get a couple folks that can be champions of this and, you know, as always choose the folks that have influence and respect and I think that again, having the conversation doesn't need to be as broad and kind of complete as ours as our process, again, you know, very, very large organization. But I do think that just even that practice of getting a couple of senior leaders together to then go down into their leadership to gather some input as well, because the, you know, we spend a couple of months going down into the organization and talking to folks about cybersecurity risk, about legislative risk, and we get feedback from kind of those frontline folks. So again, I think it's just, it's a part of the conversation. And I think you could, you know, it could evolve into something larger, if you, you know, kind of focus on a couple of key issues first.

Scott Nelson  30:32  
Looking back through recent history, from a risk standpoint, what was expected versus unexpected in health care to you and what could have been done differently?

Brett McClain  30:40  
Well, I think the probably, in terms of unexpected is, here in California is really, in particular, the issue of kind of those catastrophic events that can happen at the same time. And we saw a couple, we saw a little bit of it, right, we were in the middle of a pandemic, one of our community partner health systems also had a cyber attack at the same time, we had a difficult fire season one of those years, and then just recently, we actually had a hurricane come through San Diego, that ended up not being a big deal, but actually was for our Coronado hospital, probably the only kind of health care facility that got hit pretty hard and and it got hit pretty hard. I think that is the dealing with you know, the multiple kind of catastrophic kind of outside external, you know, nature type things are very, are very difficult. And, you know, the the challenge of oftentimes relying on the same people to help manage that helps to identify sometimes that you need, you know, additional resources or new different types of resources. And so that that has certainly been a challenge. I think, you know, the other the other one is certainly the the things that can sometimes come out of left field, out of the legislator, both again, locally, as well as nationally, and making sure that you have the right people to understand the nuances of that, so that you can help educate those legislators that are going to be voting on that as well. So it's a team effort.

Scott Nelson  32:13  
Now looking forward during this year, maybe even beyond what do you see as potential issues and how to be prepared? You mentioned cyber, staff, multi things happening at one time, are there things that you're looking at that you're saying, yeah, these are, these are ranked higher on our priority list or on our categories that we're expecting that something may happen or come up in one of these areas?

Brett McClain  32:32  
Yeah, you know, workforce is, is at the top of it, and it because it impacts our access to care, and impacts the ability for the our community to get care when you have reduced number of folks that are providing that care, or that are supporting the provision of that care. So that is a significant focus for us and will be for a long time. We've taken some steps to develop internally some approaches to develop our own team. During COVID, we actually built an innovation and education center. It is has a full operating simulation center with full patient rooms and operating suites and technology rooms and all of that. And our goal there is to be able to take our current staff and provide them a career that they can envision and to get the skill sets at a single place. It's also connected video, as well as with other forms of technology to all of our facilities so that we can have training happen in one way, the right way, high reliability way, at one time. And so we've made some investments on that. So that's that's going to be life's work, though, to be able to impact that. The other one is really kind of strategic agility. Even though San Diego is a very mature health care market our ability to strategically offer services and maybe areas that that we haven't before, San Diego is not a very it's not a growing community, it's pretty level in terms of its population growth, so it's us about us being able to understand what maybe market dynamics are happening in certain areas versus others, and how do we be at the table in those communities that maybe we're not in right now. And also to be able to strategically change our business models when appropriate to match the need as well as to match potentially some, you know, physician partners that you know, want to look at kind of a coordinated model with us that differently than it has been in the past. So those are probably the two others that are way on the top of my mind at least.

Scott Nelson  34:45  
That's a great point to close our conversation. Brett, thank you very much for your time and sharing your thoughts and experiences today. I really appreciate it.

Brett McClain  34:52  
Appreciate it, Scott. Always nice to talk to you.

Scott Nelson  34:58  
Thank you for listening to The Risky Health Care Business Podcast. You can listen to all episodes from the resource center page of the SpringParker website, springparker.com, or click the Listen link in the show notes to listen and subscribe for free on your platform of choice. And remember, accelerating health care performance is achieved through creativity, not just productivity.