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The MMH Vision, striving to be a regional leader

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According to the Business Dictionary, a vision statement is “an aspirational description of what an organization would like to achieve or accomplish in the mid-term or long-term future. It is intended to serve as a clear guide for choosing current and future courses of action.” After many hours of reflection and a few moments of writers’ block, I present to you the Melissa Memorial Hospital vision statement.

We strive to be the regional leader in providing
comprehensive services,
compassionate care,
and community wellness.

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Provider Engagement

One area of importance in healthcare, that used to be overlooked is provider engagement/satisfaction.  Studies have shown that it is the most promising means of improving performance, decreasing errors, and improving patient care/experience. The goal of provider engagement is incorporating providers’ input into operational agendas instead of merely imposing new strategies over which providers have no say.

Engaged providers approach their work with energy and enthusiasm, are dedicated to their patients and truly committed to the improvement of their organizations. In contrast, disengagement among providers can pose a serious impediment to achieving an organization’s goals.

An organization’s culture is profoundly affected by increasing engagement among providers and other clinical staff. Dyad and triad leadership models — in which providers, clinical staff and administration work together on some level of management — create a trickle-down effect through the rest of the organization, because each group contributes its perspective of the business and can more efficiently solve issues.

Additionally, the act of bringing provider and clinical leaders to the table with administration helps flatten the traditional health hierarchy in which providers serve as the clinical captains but are not really integrated with broader leadership.

In the rapidly changing healthcare landscape, this is more important than ever.

With that being said, MMH did the first ever provider engagement/satisfaction survey.  This baseline survey will help with creating an excellent healthcare system in our own little town.

For our annual provider satisfaction survey we used this methodology:

  • Questions developed by Lane Looka, FNP
  • Put into an anonymous survey monkey
  • 13 questions with sections for comments
  • 1-4 scale used 1 is the lowest score and 4 is the highest being the numerator and percentage determined by dividing by numerator of 4
  • 92% participation rate with 11/12 providers surveyed, all contracted or employed (including specialists)
  • Benchmarked against 19,270 respondent Medscape National Provider Compensation/Engagement Survey

provider sat survey results (1)

Overall the need was expressed, as it was with the employee satisfaction survey, that communication is an area to focus on for improvement. A communication planning meeting between management and providers will take place soon to work together on a solution.

Looking forward we aim to maintain this high level of provider satisfaction/engagement. We will continue to work on areas needing improvement and hope you share in the sense of excitement we feel to build on the foundation we have in place. Again and always, thank you to each and every one of you in the MMH family, you are what makes this place flourish.

A more in-depth look at results:

  • 92% participation rate giving high confidence of survey accuracy
  • Overall satisfaction, or net promoter score measured at 82%
  • High question score is 96% of providers surveyed were satisfied with their schedules
  • Low point is 55% of providers satisfied with how they receive feedback on thoughts by supervisors
  • Medscape shows that the overall satisfaction rate of family medicine is 46%, MMH scored 78% higher at 82%, the highest overall score on national survey was Dermatology at 64%
  • Medscape showed that 53% of family medicine providers were satisfied with pay, with 81% of MMH providers satisfied with pay

Giving every employee a voice

Yearly employee satisfaction surveys allow each member of our family the opportunity to have a voice. They can share what they like and what they don’t like. One thing I would add is the request that when you don’t like something, offer a solution.

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A few things to note:

  • The same 23 questions have been used for five years
  • All answers are anonymous
  • Answers are benchmarked against the Press Ganey national scores

emp sat survey

We are at the top of the best in class terrority as benchmarked from Press Ganey, with scores that rank far higher than both their best in class average as well as the national average. As a result of this survey, the employee benefits committee is working on recommendations for employee education and an organizational communications plan is being developed with hopes for implementation for 2019.

As we look to the future it’s good to know that the team we have wants to be here and enjoys working together. While there is always room for improvement, with the right culture it’s an improvement as a team and guaranteed for success. Thank you to each and every one of you in the MMH family, you are what makes this place flourish.

More in depth look at progress:

  • 84% participation rate gives this survey a highly validated bell curve
  • Overall satisfaction rate for 2018 was 89% for the prior 4 years was 2014: 44%; 2015: 45%; 2016 84% and 2017: 82%
  • Overall job rating question showed 96% satisfied in 2018; 2017: 95%; 2016: 93%
  • Likelihood to recommend MMH as a good place to work was in 2018: 95%; 2017: 92%; 2016: 91%; 2015: 57% and 2014: 63%
  • Employees here recognized for job well done highest increase from 77% to 89% (area of focus last year)
  • Area of opportunity is orientation and training had slight decrease 2018: 87%; 2017: 88%; 2016: 81%; 2015: 46%; 2014: 32% (area of focus this year)
  • Majority of comments were geared around education for all staff
  • MMH in best in class territory as benchmarked from Press Ganey
  • Recommend MMH as a place to work in 2018: 95%; best in class: 87%, National Avg: 77%
  • Employees recognized 2018: 89%; best in class: 74%; National Average: 64%
  • Senior Management is concerned about employees 2018: 80% (2015:36%); best in class 71%, National Average.: 56%
  • I have not considered resigning in last 6 mos 2018: 83% said no; best in class: 68% said no and National. Average: 60% said no

Strategy and new positions

We have an exciting week ahead!  Joe Tye will be here this week to help us go from good to great.  Also, we have a lot of good things that will be happening throughout the year.  The first part of my blog post will be discussing our strategy for the year, and the second part will be three new positions for the organization.

In the middle part of the year, administration gathers market data, thoughts from medical staff, you all, the board, trends for our town, region and nation.  We then compile this data, and then decide what the organization shall tackle in the next calendar year.  If you have been here for the last two years, you have seen this process, and know that we are a progressive organization that understands diversity in services is needed to survive in this ever changing healthcare landscape.

Two years ago when I started (Feb 2nd 2016)  we were a $14.7 million organization.  As of today we have formed a great team, and are now a $20.1 million organization.  We plan on reaching $24 million this year.  This is by focusing on services that are not usually done by critical access hospitals (retail pharmacy, optometry, joint programs, outreach lab services).

Below is the high level 2018 strategic plan dashboard.

Strategic Goal Who is Responsible
Strategic Plan Total Goal Achievement CEO
1.0 Growth  
1.1 Mental Health Integration-to bring in mental health workers in the clinics on a weekly basis. Heather, Trampas, Julianne
1.2 Dental/oral service line-business plan to start a full time dental practice. Heather, Trampas
1.3 Chemotherapy program-data shows that 3500 times a year someone leaves our community to receive this service Julianne, Amy
1.4 Outreach Lab service-innovative service where MMH will be employing phlebotomists to draw blood for primary care offices along the front range and courier samples to MMH to have our amazing lab staff run and result out the samples. Also, switching reference labs.  This results in a nice revenue stream for the org to reinvest into equipment and expense reduction (payoff) Trampas, Megan, Heather, Wes
1.5 Accountable Care Organization-Medicare Shared Savings Program where we will be focusing on population health and Medicare wellness exams. Heather, Julianne, Trampas
1.7 Increase primary care via OB strategy-bring in more OB practitioners from Banner to ensure that the patients return to us for the rest of their care.  Some hospitals try to keep the entire family for all care…Banner does not.  Trampas, Heather
1.8 Increase swing bed and in-patient utilization-study the transfers that we do to see where we can provide more services to keep at MMH.  Continue working with Banner and UChealth to receive all of the swing bed patients we can.  We typically have 1 to 2 patients come back for swing bed care from Banner every week.  Julianne, Trampas
1.9 Implement Paramedic in ED or community paramedicine-train paramedics for more use in the ER and do home primary care/social services type visits. Heather, Julianne, Trampas
Total  
2.0 Employee/patient investment  
2.1 Leadership development-developing training programs for leaders to have the tools to effectively lead their departments (accounting, HR, conflict management, culture) Jennifer, Trampas, Megan
2.2 Culture training-Joe Tye alues coaching where we want to have everyone take ownership in MMH to ensure the patients and each other are taken care of to the highest level-“proceed until apprehended” Trampas, Jennifer, Heather, Lane
2.3 Financial training for employees-Wes will be sharing his expertise with managers via a healthcare master’s level finance course he will teach twice a month all year.  Wes
2.4 Improve staff retention-determine what we can do to get our better than average turnover of 17% down to 10-12% to be one of the best in this category…and retain all of you…our rockstars. All
Total  
3.0 Community  
3.1 Daycare project facility design and selection-Move forward with the Holyoke Daycare Initiative 501 (c)(3) on the grounds of MMH. Trampas
3.2 Master Community Plan-start a plan for the land that MMH owns around the hospital for the potential of: assisted living, senior housing, staff housing, nursing home etc.  Trampas
Total  

You can see that a lot of these items are to better equip the entire workforce at MMH to become the best that they can be.  We truly want to be the best place for you all to work at, and the best place for our patients when they choose us.  I will go into detail in each of these items at our employee forum in Feb.

New Positions:

There are a couple of new positions that MMH has hired for that we have not had before.  These are Public Affairs Specialist, Wound Care Nurse, and EHR Support Specialist.

The Public Affairs Specialist will report to Megan and be responsible for the MMH story, internal and external relations, communications, public information officer during disasters, marketing, events, and awards and recognition…and so much more.  Elizabeth Hutches will be starting Monday the 22nd.  She has experience in each of the above areas.  Knowing the work that she has done for the chamber of commerce, her drive for success, healthcare experience and strong business relationship skills, she will be a great asset to MMH.

Wound care nurse is a new position.  Since we have moved the wound care to the specialty clinic and focused on it to being a service line, it has grown to 75 to 100 visits a month!  This is pretty cool, however, this is way too much for our gracious staff who have assisted in the service (Krista, Barb, Deaun, Mary Kay, Julianne, Heather and all others who have helped).  This position will be responsible for the care and coordination of this service line.  We are blessed to have Cindy Locke rejoin us (start date TBD).  Cindy comes from us as the leader of the cancer center in Sterling.  We are happy to have her back, and hope to utilize her expertise in restarting the chemo program as listed before.

EHR Support Specialist is a new position that will have a lot of implications on everyone’s workflows. Athena brings the best technology and software assisted healthcare delivery in the industry.  There are so many tools that Athena has, and we want to use this to the best of its ability.  Furthermore, this position will train all staff on the use, and do refresher training on this system.  We have invested a serious amount of time and money into Athena, and the expectation is to use it to the highest level.  I would like to welcome Fabian Basurto.

Fabian retired from the Army after 20 years of military service and spent the last 9 years contracting with the DOD.  He has been an army medic, dental tech, lab tech, has coding experience, has a radiology certification as well as a HIPAA certification and has been a EHR trainer/Healthcare Informatics for the last 12 years.  Fabian’s most recent stint was at the Naval Hospital in Sigonella, Italy conducting instructor led and on-the-job training for 520 EHR clinical end users.

 

 

Making my rounds…

Hi All…as part as the investment back into the culture with the Florence Prescription book, leadership development, financial training for managers, transitioning to accountability to ownership; you will see that the senior leadership team will be doing things to address communication, and listening to your ideas that you have given us via multiple venues. You may have already seen the email from Heather about joining the employee benefits committee.  We are also looking for a part-time public affairs specialist to take care of external and internal communications (and a whole host of other marketing/PR items) to bridge gaps.  One thing that I will be doing is intentional rounding to listen to you all, and give you all a voice beginning Jan 1, 2018.

What the heck is intentional rounding? It is where I will be coming around to each department once a month, and visit with one or two random staff members of that department.  I will be asking a couple of standard questions to get feedback on how we can better serve you.  These questions are:

  1. How can we improve daily work conditions for you?
  2. What can we do to improve work/life balance at MMH for you?
  3. Tell us what support you need to take the patient experience to the next level?

I will then compile the answers for a set monthly leadership meeting to see where we can improve the organization as a whole. I will communicate via this blog, and in person what any items may be. This may be a little awkward at first, but I hope to have amazing open and honest communication…my overall goal is to ensure that everyone is heard, and we work on the things that matter most to you to make MMH the very best place to work. However, we can’t do everything; but we will do our very best to ensure that this is the very best place to work.

Culture of Ownership.

Merry Christmas to you all!  I will be coming around the hospital Monday the 11th handing out the Christmas cards for those of you that have not got them yet.  In addition to the Christmas cards I am handing out a book that we have purchased for the entire organization.  This is called The Florence Prescription: From Accountability To Ownership by Joe Tye.  This should be read by 1/23/2018 (whoa 2018?) as this will kick off what I am calling “reinvesting back into our most valuable asset…you all”.  I will get into the specifics in a moment…

I don’t know if most of you know my background prior to becoming a CEO here at MMH.  I started my healthcare career 25 years ago when I was 16 (if you are doing the math I am 41).  Back when child labor laws were different, and you could be a Nurses Aid in long term care units.  I was an aide in high school, and realized my true calling was in healthcare.  I got my degree at UNC in Kinesiology with a minor in Community Health thinking I was going to be a physical therapist.  I did my internship and got a job in cardiac rehab after graduating.  I worked at Parkview in Pueblo where I did  cardiac rehab, and then was crossed trained into cardiac treadmill testing then subsequently the cardiac cath lab.  I spent several years in this realm moving to Denver to work at St. Anthony’s cath lab and cardiothoracic surgery program were we were trained to do all of the procedures from an electrophysiology study to a bypass surgery.  This was one of the most demanding jobs I have ever had due to being a level 1 trauma center, and  was in one of the poorest neighborhoods at the time.

I decided then that radiology was my calling, and went back to Pueblo to earn my Radiologic Technology degree.  While I did this I worked as an anesthesia technologist at St. Mary-Corwin in Pueblo to help make ends meet.  I was responsible for 20+ anesthesiologists, their inventory, machines etc.  I then graduated and moved to Sidney, NE where I spent 10 years doing XR, CT, MRI, US, Dexa..I moonlighted at several small hospitals in NE, and helped install and train on multi-slice CT scanners in small hospitals (I did Wray’s current unit).  I then wanted to make a transition into administration.  I got my Master’s in Healthcare Administration from Univ. Nebraska Lincoln, Univ. Nebraska Medical Center Clarkson College (I am not a Husker fan, sorry).

I was then fed to the wolves at Middle Park Medical Center as the Chief Operations Officer.  MPMC was the nation’s first critical access hospital system in the United States, three hospitals and five clinics under one CAH license.  Here I was Interim CEO twice, Interim CFO and had CIO (chief information officer) added to my permanent job duties.  At one point I was doing MRI’s, COO/CIO and Interim CEO during one month…I did this because I felt a sense of ownership over my work, and my hospital…and the jobs were vacant, patients needed MRI’s and the hospital was without a CEO.

I am sure you all are wondering is this bragging or what?  I can’t lie…I am proud of my accomplishments…however, my point is that up to 2011, I was a negative, toxic employee, at every single job…it all felt the same.  Everything that went wrong was someone’s else’s fault, I did not take ownership on anything.  I despised administration.  Nurses didn’t know how to put a simple chest xray order in, so they must be stupid.  Doctor’s put a generic abd pain on an order for a CT, so they must not have a clue and are on a fishing expedition or paid a percentage of revenue from the hospital.  Why are they calling me in at 3 am for a pinky xray…stupid inconsiderate patients.  We just did 92 radiology exams between the three of us today, but administration won’t give us more help…they don’t care.  I take all of the call, and nobody else helps out.  The EHR is crap…it’s not anything I am doing it is all their fault.

I was mad at things out of my control, with no knowledge on why they were happening.  I was withdrawing from work and home-life.  I wouldn’t attend any hospital function because I didn’t like anyone, they were all to blame.  I was flying under the radar collecting a paycheck…had my best façade on when dealing with patients.  I hated my job, because nothing ever changes.  I would leave a job because it was everyone else’s fault…because the grass must be greener on the other side, right?

This all sound familiar to you, have you had these thoughts?

Enter Joe Tye in 2011.  Joe was brought in to Sidney Regional Medical Center to help create a culture of ownership.  I read his book (mentioned above), and thought meh..it was decent, but just another administration flavor of the month.  When Joe did his onsite work, and his presentation…I was literally floored.  I was one of the toxic employees that he was talking about.  His pledge is excellent, and I credit it with me loving my job every single day.  I used it to make the leap that I did.  I still use his pledge to this day:

Monday-I will take complete responsibility for my health, my happiness, my success and my life, and will not blame others for my problems or predicaments.

Tuesday-I will not allow low self-esteem, self-limiting beliefs, or the negativity of others to prevent me from achieving my authentic goals and from becoming the person I am meant to be.

Weds-I will do the things that I’m afraid to do but which I know should be done. Sometimes this will mean asking for help to do that which I cannot do by myself.

Thurs-I will earn the help I need in advance by helping other people now, and repay the help I receive by serving others later.

Friday-I will face rejection and failure with courage, awareness and perseverance, making these experiences the platform for future acceptance and success.

Saturday-Though I might not understand why adversity happens, by my conscious choice I will find strength, compassion and grace through my trials.

Sunday-My faith and my gratitude for all that I have been blessed with will shine through in my attitudes and in my actions.

In the next month, we will be reading the Florence Prescription, be doing a culture assessment, working on the MMH mission, vision and values, Joe will be on-site Jan 22-24, and we will embark in a great transition to accountability to ownership at MMH.  I can’t wait to get this going.

New Docs signed!

Hello All!

What a crazy last couple of weeks.  I am proud of how we all handled the Athena conversion.  Things are getting resolved at a rapid pace.  One way to think about Athena, is that it is pushing us to do everything in real-time, it has patient safety at the forefront of its platform.  You may be asking what that means… take a look at your clinical inbox…it requires you to verify many tasks, look at labs/x-rays and medication refills and requires action so nothing gets missed.  It requires us to enter an action item for each of the items.  If we do not stay on top of this, we will get behind.  I am excited to see the workflows coming together.

I want to end the week on a great note.  We have signed not one or two, but four new Docs.  Two are family practice, two are specialty.  Dr. Daniella Boyer has signed on to practice like Dr. Wilson and her start date is after she finishes her residency on July 31, 2018.  One not so new Doc…Dr. Kevin Cuccinelli has agreed to provide 120 hours per month ER/IP/Obs/Clinic coverage.  Dr. Yakel, our Podiatrist, will become an employed Doctor like Dr. Schiefan.  His hours will not change, but we will assume all billing for him.  Dr. Mike Solomon, our cataract surgeon (ophthalmologist) will begin in Nov.

Also, Dr. David Mendez, our first resident, begins Tuesday 10/3/17 for a month of seeing patients in the clinic and the ER etc.

Thank you all for your hard work!

Go Live!

Woohoo!  A long journey is getting ready to hit a major milestone!  Hopefully you all know what this is.  Tuesday, 9/19/17, at 0700 hrs…we move forward with using Athena Health for our EMR!  This will be one of the biggest things that MMH will go through.  These past few weeks has been challenging, everyone has experienced many emotions: excitement, anxiety, fear, happiness, pettiness, apprehension etc.

There will be many more emotions, there will be bumps in this process…things will crash, things will work really well, things won’t be as promised from sales people…things will be worse off, at the end WE WILL PREVAIL and will be better.  I challenge everyone to attack this with relentless curiosity, positivity, courage and hit this project with the utmost ferocity that we will serve our patients, be patient to ourselves and be kind to one another, and come together to make MMH the very best organization we can.

Surely we will end up where we are headed if we do not change direction. —Confucius

Change is hard, I admire everyone’s courage to take this journey together.  Let’s take this opportunity to take our vulnerability, this time where we can mold MMH to be the healthcare provider of choice, and employer of choice.

Here are a lot of fun things and ways to help de-stress:

Friday, September 15th

  • Distribution of shirts- 10:30 am

Tuesday, September 19th

  • Free massages- 1:00 p.m. – 4:00 p.m.

Wednesday, September 20th

  • Free massages- 9:00 am- noon

Tuesday, September 19th – Friday, September 22nd

  • Coffee bar- Mornings
  • Cookies and canned pop- 2:00 pmMonday, September 25th – Friday, September 29th
  •  Coffee bar- mornings
  • Cookies and canned pop- 2:00 pm

Setting the Direction

Happy beginning of the week!  The past month while everyone is prepping for the Athena conversion the board and senior team has been focused on multiple different things.  The board retreat was held on August 10th, where a strategic update was given based on financial data, year to date volumes, market analysis, the employee satisfaction survey, external trends and other data.  This was a very good retreat catered by the MMH Dinning Extrodinaires…it was a tasty meal (did you know Sue, Spencer and Fil served 1,600 meals in August?  Wow!)  After this retreat the teams emerged with high level strategy to put into place for the next 18 months.  These items were touched upon in the past managers meetings.

This past week on Thursday and Friday the senior team had it’s retreat:

 

What actually happened:

retreat 3

We took the information from the board and managers, and turned it into tactics and plans.  We also took information from a 700 question leadership survey called the Hogan Leadership Assessment that each of the senior team member took, along with the employee satisfaction survey, and identified strengths and weakness in our fairly new senior leadership team.  This was all facilitated by Tony Blake from Strategic Impact.  Tony is a highly regarded expert in leadership, strategy, culture etc.  He took DaVita and beat Microsoft out for best culture in the United States a few years ago.

retreat 1

By now I am sure you all are wondering what we are looking at for strategy for the next 18 months.  Here is the high level list: Mental health integration, dental clinic, chemotherapy, day care, staff education, organizational culture improvement, financial education for non-financial staff, leadership development, staff retention, swing bed and IP utilization, retention of family medicine through prenatal and post-partum strategy, increase primary care utilization via accountable care organization, process improvement methodology, and outreach lab services.

The team also developed team norms in which to function under, did a hit or miss inventory from Jan 2016 (my arrival) to today, and focused on mission, vision and values of the organization.  After the dust settles from the Athena conversion, there will be a team put together to focus on the mission statement, and subsequently the vision and values that we all will abide by.

We will be having a quarterly town hall coming up soon, and we will go over this more in detail.  If you have any questions feel free to reach out to me.  I hope everyone has a wonderful week!

 

100,000 providers strong!

Hi All! Had a great strategic client forum for Athena Health the past few days. There are a lot of very cool things happening with Athena that by virtue of the cloud and network…no other partner can do.  A few of the new things:

  1. Secure mobile app for Athena Net to be on your phone/mobile device
  2. 100% pre-auth service…this takes their rules engine, live operators and power of the network to auth all procedures from surgeries to medications to DME…the statistics on their success is amazing. In fact insurers are very happy with how they do this. A top 5 reason for denial is lack of pre-auth. They can obtain a pre-auth within an hour for urgent exams.
  3. Increasing the speed of their network
  4. They have over 100,000 providers on the network

Due to having this many providers on the network they can drill into data quickly to show that:

  1. Text message reminders are the best at preventing no shows. 4.2% of patients that received a text message no-showed compared to 10% for phone call reminders. This includes Medicare patients!
  2. A spike in Lyme disease has enabled Athena to assist the CDC to get warnings out to the public about tick bites.
  3. They can see that while the average wait time for the US for a wellness exam is 30 days, 27% of schedules are never filled in the past 30 days…meaning that with the daily cancellations and no shows every day schedules go unfilled, so they developed a new text feature that when a no-show or cancel happen it will send text messages out to people that are on the schedule with similar appointments to ask if they want to be seen now and give the practice a call to schedule ASAP. Pretty cool
  4. They are collecting data on the hospital side that re-works the medication bar code scanning workflows for improvements…these are just a few of the new items.

This is a great segway to the first question: Senior Management is always out for education, what about other employees who work directly with patients, could they go off site for education or training? ABSOLUTLEY! I don’t believe I have turned down a request for this, unless it was a timing issue, extravagant cost (I was asked about a $6,000 off-site 1 week course once) or did not pertain to the job. I always encourage to look for the free trainings first. For example, Athena Health has paid for this trip to Boston. At a strategic lab trip I took to Austin last month that organization paid for. The trips for Athena implementation team, selection teams etc. Were all paid for. For the Colorado Rural Health Center Rural forum and annual conference there is typically a scholarship to help offset the costs.   

I understand that not everyone can find these and afford them, however, I encourage offsite training as needed as it pertains to your job. However, be prepared to present what you learned to me or others to ensure that you all are learning. Also, training costs over a certain amount are subject to employment contracts. Unfortunately, some folks will get a lot of training and then leave the organization. As an organization we should invest in our employees, however, we also have to protect that investment as well.

Specialty Clinic along with the Specialty Clinic Providers and our patients we provide so many different services and our patient care is our main priority. The specialty clinic is a pretty special area (pun intended). It is our strategy to create access to our community, this includes specialty clinic. It was our goal this year to surpass a 50% specialty clinic market share…we are projecting to beat that even with-out the Coumadin clinic and eye clinic numbers. Add those numbers in and the specialty clinic is projected to see nearly 5,000 patients this year compared to the 7,300 in the primary care clinic. This creates access access access all around. What is cool also is that the primary care clinic is on schedule to have its 3rd best year in history. Keep it up!

I like my co-workers and having adequate ancillary help, ward clerks, CNA’s etc.  I love all of my co-workers (you all!) Glad to hear on the rest.

 

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