A leading healthcare system weighs in on America’s public health landscape

Full transcript below: 

David: Welcome, everybody to another episode of ICF's "Public Health Enterprise Podcast" series. I'm David Speiser, executive vice president for strategy and strategic planning at ICF. And I'm very excited to welcome my guests today. We have a trio of clinical leaders from the Inova Healthcare System. And rather than me introducing them, I think I will ask them to introduce themselves. So, Steve, can you kick it off?

Steve: Hi, everybody. David, thank you. My name is Steve Motew. I am the chief, clinical enterprise at Inova Health System. I am a vascular surgeon by background and have the incredible pleasure of having worked at Inova Health System for the last 15 months--in a role that partners me with some incredible team members, two of whom will be introduced in a moment and really have the oversight of our clinical enterprise. And for Inova Health System, the clinical enterprise represents all outcomes and operational components of our core business, which is delivering world-class health care to our communities. I am from Chicago originally and am excited for what we've accomplished here at Inova in a very short period of time with our leadership team and for what is ahead. I also do have a master's degree with a focus on some components of public health. So, I'm looking forward to discussing this today. Thanks.

David: Oh, terrific. Maureen, could you introduce yourself?

Maureen: Sure. Thank you, David. I'm Maureen Sintich. I'm the system chief nurse executive for Inova Health System. I represent over 6,000 nurses and another couple of thousand clinical technicians. And I'm very fortunate to be a part of the system and also working in partnership with my colleagues, Steve and Chapy, who you'll meet in a moment. I've been with Inova now for three years. I am passionate about the impact and influence that nurses make across the entire continuum of care, and certainly, the health of our communities is an area of focus for us at Inova. Thank you. Great to be here with all of you.

David: Thanks, Maureen. And Chapy, last but not least.

Chapy: Absolutely. Thank you, David. And thanks for including me in this podcast. My name is Chapy Venkatesan. I'm the chief quality and safety officer here at Inova Health System. I'm going on about a year at this point in this role, but I've been with the Inova since 2004, starting off as an internal medicine physician working primarily in the hospital. And I feel that that background has given me quite the lens on understanding what my role could be in being able to care for the patient in their entirety, across the continuum that spans obviously outside of acute care. I'm really happy to be part of this group, learning a lot from Steve and Maureen, and excited for our discussion.

David: Great. Well, thanks for joining me, all three of you. And just for total clarity, and to eliminate any uncertainty, I actually know these three professionals. I play a volunteer role at Inova and so these folks are not just leaders in the community, but they're friends of mine and colleagues as well. So, thanks, everybody, for joining. Obviously, Inova is an incredibly important health care provider in the Northern Virginia region. How do you all think about your role in public health as opposed to clinical care? And, you know, Chapy talked about the continuum of care, which goes obviously beyond acute care in our facilities. But can you talk a little bit about how it overviews role in public health and how that comes about?

Inova’s approach to continuum of care

Maureen: Certainly. Inova's primary role is in direct clinical care. But if I paraphrase our mission in that we provide world-class health care in all the communities that we have the privilege to serve, you know, the health of our community is critically important to us, and how we provide care and our ability to make an impact. And so, we believe that it's important to be involved in the community members' lives across the entire continuum of care--from wellness to the acute care setting--as we transition back home. And so, again, the relationship between the health system and the community is continuous and our ability to make an impact in that perspective.

David: How does Inova interact with the community in terms of wellness, right? So once someone either leaves the acute care environment or never enters into it, how is the Inova influencing kind of wellness of the community kind of beyond our facilities?

Maureen: We've created a network of both primary care and specialty practices, and believe that everyone should have access to health care, regardless of their ability to pay. And so whether it be community-based clinics that we've incorporated into our continuum of care or the house calls program--staffed primarily by advanced practice providers, and physicians where we are able to provide primary care for our aging communities in the home, to assist them and support them so that they don't have to come back into the acute care setting--and really listening to the community members. We're learning every day from those who serve on our patient and family advisory councils what is important. What is most important to them and asking that question. And so, we learn, we grow, we'll develop new programs along the way as we're meeting those needs.

Steve: David, this is Steve, I can add a little bit to Maureen's answer to your question about wellness. A lot of that really depends on what do we define as ‘wellness’ and well-being? We could probably talk for hours on creating that definition as it relates to our communities and public health, in general, from some things I think we could talk about later with social determinants of health. However, there is a point of view--particularly as an integrated health system--that connectivity to general wellness as it relates to a primary care relationship is very foundational. Recognizing the challenges that some may have in establishing that relationship, wellness really is rooted in that relationship. So, one of our driving strategies is to create the opportunity to connect with a primary care provider. And that can take all sorts of different flavors, whether it's a team of providers or a pharmacy tech who is assisting with medications to advanced practice providers--such as nurse practitioners and PAs--and, of course, to primary care physicians. And so, to clarify that connectivity to wellness where we'll look at risk factors, and not just treatment, but prevention as well, is really rooted in the ambulatory space.

Chapy: I might just add, onto what Maureen and Steve had mentioned, just sort of round out some of that discussion. I think that one of the things that you would ask, David, was around just kind of across the entire continuum. To Maureen's point how we approach well-being in the community before a hospital episode--but certainly even after a hospital episode--realizing that often these hospital episodes are either unavoidable or actually represent a failure in some form of the outpatient treatment, as Steve had alluded to. Or it could be related to social determinants of health. And we have our eyes on how to, in a patient-centered way, transition patients from that acute care setting and really working on establishing a medical home in their community. We do have transitions of care clinics throughout the region, as Steve started to allude to, that are staffed by a multidisciplinary team that can really help patients get set up for success after hospitalization, and serve as a bridge before actually setting up an established primary care physician. So, I just wanted to kind of add that to the conversation as well.

David: Now, the idea of a medical home, obviously, brings to mind some of the efforts that folks around the country have started on in terms of building more population-wide efforts to ensure access and ensure that everybody is getting some of that preventive care, right? Obviously, we're all functioning in a very complex payments environment and reimbursement environment. How then does Inova think about serving a broad population with a variety of types and levels of coverage and some which may have an ongoing relationship with you and some which maybe has never interacted with the Inova enterprise before?

Steve: First and foremost, because we're a mission-oriented organization that is rooted in providing care and wellness for our communities, we want to be very clear that our commitment is to caring for patients, regardless of their background and socioeconomic status and ability to pay and/or their payer status. So that foundation really is core to how we devise our strategy of reaching out deep into our communities. We also recognize that care delivery is very much oriented in the communities that sit very close to our access sites. And in one regard, we have big access sites like hospitals. They're located in neighborhoods, and neighborhoods make up communities. Northern Virginia is, in some regards, you might look at it and think of it as being a relatively homogeneous, middle class, community, upper, middle, class community. And actually what we found out is the depths of diversity, in both background and socioeconomic status, race, and ethnicity, is very broad to what somebody may think to a generalization. I think that that is true of almost all communities.

During the COVID-19 epidemic, this became even more obvious to us, as we saw differential in how COVID-19 impacted different communities in each of our hospitals--and also in some of the specific micro geographies surrounding them. With the components also thinking about accesses, we understand how important it is to make sure that health care is accessible to all aspects of our community. And this drives some focus areas we have for partnerships with our federally qualified health centers, our distribution of language-focused predominantly Spanish-speaking clinics in geographies that are accessible as well.

And then there are also specific programs that are identified for higher-risk populations. We can go into a lot of detail of some of those. One would be an example is our Inova Juniper Program, which is a long-standing clinic and multi-disciplinary program that's associated with HIV patients. So, I think that's a little broader than what you might have asked, but it really is tied to the components of understanding our communities, the geographies, and access.

“There is no quality without equity”

David: No, that makes perfect sense that ties into the question you raised earlier, it might, as we'll talk about it now, which is social determinants of health. In prior episodes our guests have talked about how integrally linked health outcomes are with housing status, nutrition, justice, and equity, transportation, and a whole range of the different so-called social determinants of health. Obviously, you mentioned the disparities that exist even within what--for those that don't live in Northern Virginia--might view as a somewhat uniformly affluent area, but those of us that live there know that's not true. How do those social determinants connect with the work that an Inova does? What do you all have to do to kind of take those into account? And which, if any of them, can you have an impact on?

Steve: I'll start this, but really ask that, Chapy and Maureen, fill in the blanks. Social determinants of health, when you look at the continuum of what drives sickness--and what also promotes wellness--the vast majority of components are not rooted in how we deliver health care today, which is focused on acute episodes in our facilities, and stomping out illness and sickness wherever we can. We're very good at [inaudible] meaning both Inova and large healthcare systems in general. The genetic components play a very small role. And the largest component, as you know, that drives outcomes of health are what we would put under the title of social determinants. Those are the broad components of environmental, cultural access, socio-economic, environmental factors that impact humans.

And so, the short answer is, we're relatively early in that journey, and working towards trying to at least gain an understanding of how that affects our specific population. One example would be starting to approach and enter the conversation amongst our teams of just asking and understanding. So, I think that's about how we begin that conversation. The next stage is really-- and this is still an open question--where does the line between skillset, resources, and responsibility sit between a health system and social determinants? I think it's wide open, and I'll ask Chapy to weigh in as well.

Chapy: Yeah, absolutely. I think that quote I heard from the Institute of Healthcare Improvement is, "There is no quality without equity." And I think that we have been fortunate to be able to--as Steve described on this journey--partner with the Institute of Healthcare Improvements and be a member of one of their Leadership Alliance subgroups regarding social determinants of health and learn a lot through that partnership. One of the things that we do have in place is a steering committee on a system level to help guide the work of our Community Health Needs Assessments. And one of those goals is really starting with the basics and being able to actually obtain all the information on the front end to be able to understand the status of social determinants of health in our patients in our community members. So that is definitely an initial step along that journey.

Certainly, there's a very, very large realization about the impact of all of these determinants on our patients' outcomes. And I can tell you, from the provider and nurse and remainder of the team perspective, this is the type of work that drives people at Inova, that they get up in the morning and want to be able to participate in. We're really excited about where we'll go next with this. Maureen, I don't know what other stuff you would certainly want to add to this conversation.

Maureen: Chapy, thank you. Just building upon what you said, I think that we continue to learn, not only from our communities, but from our own people and taking the advice from our diversity inclusion council and learning from them about many of our communities that we serve. And as Steve said, asking the question, calling the question, and learning from our community members, and allowing our team members to guide us through that process has been extraordinarily insightful and helpful.

Connecting the data dots between hospitals and their communities

David: Well, I know that there are a number of pilot programs going on now to accelerate the dissemination of accurate information from Inova and from Inova providers right out into the communities. And I know some of that is leveraging general communication channels, and some of them are leveraging innovative channels like specific categories of Inova staff. Turning our attention from the community to the other components of the public health enterprise, how does a big regional provider and a leader like Inova interact with our local and state public health officials? I mean, what are the connection points? What are the regulatory relationships? And how are you guys connected to them?

Chapy: I could start on that one. I've become more familiar with this, as we've progressed during COVID. But certainly, I would say two things that have been really in place, I think, from a perspective of interactions with our local and state health departments. One is that we do have our local health department medical directors. They participate in our infectious disease meetings across the system. And that's a really, really good link to have. And then, in addition, we have representatives on statewide phone calls that started really in February regarding emergency preparedness and then the ongoing response to COVID with the Virginia Department of Health and VHHA, as well.

David: And VHHA is the?

Chapy: Virginia Hospital Healthcare Association.

David: So, I'm going to assume that Inova data is an important component of the state data that I look at every morning. How does Inova end up feeding information up to say, the Fairfax County or Northern Virginia or the State of Virginia public health officials? Where does that data come from? How do you generate it? How does it get transmitted?

Chapy: Yeah, absolutely. So there's multiple different aspects of that data that we share from things related to resources and availability of things like our supply of tests, personal protective equipment, special resources--such as ventilators or actual flat space and beds--as well as general information about staffing. Then in terms of more specifics related to results, certainly, information about rates of test positivity, number of patients who are hospitalized, and at what level of care and the number of patients who have been healthily discharged from the hospital, and those who have unfortunately died. Those are all certain data points that we share. There is some component that is relatively automatic, but there are others that really do require manual uploading. So, we submit our data through VHASS--which is an emergency management extension of the state--and also directly to HHS.

In terms of some of the things that we've learned is that we've been able to use our electronic health record to create reports that are relatively seamless for us to get information. However, to upload into the different required portals, there has been some manual work, which to me seems to be related to potentially the fact that we don't really have a common EHR framework across all the reporting bodies or any direct interoperability between all of those either.

David: You know, several years ago we had the health information exchanges, and those I know were stood up in part in Northern Virginia. Are those still operational? Do they play any role in this or have they been kind of overtaken by events?

Steve: You know, David, I don't know the answer to that. I think I can speak to that a little bit more globally in that--as Chapy mentioned--the vision and sort of Inova of true health information, interoperability, has yet to be realized, at least in the degree that's necessary. In some ways, the automatic sort of upload of data through VHASS and other like systems is a form of health information exchange. So, in that regard, I think that there are bits and pieces of it in the public health realm. From a true interoperability and sharing of information, which is absolutely the key, there has yet to be identified--or I would say universal acceptance of standards to the degree that's necessary.

And I think that's really a national challenge meaning, we've had a lot of conversations recently on the requirements for health transparency. Internally at Inova Health System, we've taken and are promoting the approach of openness of records to patients and their families with immediate return of lab results, access to the notes. And we have already leveraged the tools that are built within Epic, which is our electronic health record, to facilitate that. And there are connectivities through, for example, our signature partners, which is our clinically integrated network. However, it still requires third-party intervention to adhere or to share the information. So, I think that it's an opportunity and clearly a gap.

David: The provision of healthcare information upwards, if you will, right, to aggregate it across different geographies and jurisdictions is obviously critical to trying to make coherent fact-based decisions about public health. Do you all get information back down the other way from the system? You know, maybe it is not as urgent. I know, you probably get updates from CDC and other places. But do you get kind of population-wide health data back down from the state officials or federal officials on trends in wellness and chronic disease status and various population health metrics? Or is it up to you to kind of turf those out from other sources?

Steve: You know, this, Steve, again, I think it's a little bit of both. I think that there are data sources that are available. I don't know that all of them are... You know, we're very data-hungry as an industry, in general. And the consolidation or the availability of data from some of the sources that Maureen and Chapy mentioned, whether it's through state resources or other federal related, as you mentioned--CDC and so forth--it's there, and we access it regularly in some cases, and probably not enough in others. I do think, once again, the lack of general consistency and availability of that data is something that we're acutely aware of. The sharing, for example, where I think we did and continue to extract benefit are on some of the predictive modelings that's associated with COVID, for example, that are being run from several sorts of convener sources that we have access to. And the value to us in pulling that data, as opposed to, not much of it is actually pushed in an analytic mechanism. But we've used that pretty extensively to help with our own modeling as well.

Maureen: I guess I would also say that in addition to the quantitative data that we have submitted, and also what data we have received, we've also received significant qualitative feedback through resources and alliances and partnerships within the state as well as nationally. Those resources and what we learned contributed to our ability to redesign care almost real-time, as we were preparing for the care of the COVID patient, recognizing that we needed to increase capacity, recognizing that we had to be able to extend our flat space, if you will--to design and incorporate additional critical care beds. That information came to us in a way that we were able to train critical care nurses relatively quickly, respiratory care extenders, add nearly 300 additional negative pressure rooms to be able to provide the care for these patients across the system. And so, I don't want us to underestimate the impact that that information had in our ability to extend caring services to our communities within North America, Virginia.

David: How would you characterize, Maureen, in that context, right? And I know you know, personally, sitting in on the stand-up meetings during the height of the pandemic response how much that real-time learning was going on. It was a great kind of window into the functioning of a kind of high-performing healthcare system. If I put myself in the shoes of a smaller community hospital somewhere else in the country--and it sounds like I would have to take kind of similar actions to the ones you all took to get that same level of insight and that same level of information sharing. Because it sounds like there, as Steve said, there's no automatic flow down push of information. You're seeking it out and participating in it. And you've contributed to it, I know, and the learnings around some of the advanced learnings that have happened in the Inova system. If I'm sitting from the chief nursing officer at a small community hospital somewhere else in the country, do I have to replicate everything you all did as a system to get that same information?

Maureen: No. You know, the accessibility to information was significant through our various professional organizations. So, whether it be the American Nurses Association, the American Organization of Nurse Leaders--just using nursing as an example--there was information readily accessible. I think the challenge is to be able to focus and take the time to comb through the information to ensure that the information that you're receiving is appropriate for your organization--for your patient population--and then the ability to take the steps to implement whatever it is that you are working through. You know, I think, the nationally healthcare executives and leaders, we're a pretty tight-knit group, and we're very open and how we work together across the spectrum, across the continuum. And what I was so gratified in how open those that had gone before us, for example, colleagues in New York and New Jersey, New Orleans and Seattle, who were open to sharing, again, almost in real-time. And it was an incredible experience and a situation that we know, the world has only experienced every hundred years or so. And so, the learnings--and our ability to document what we've learned--will be very important for those who come behind us.

Connecting the data dots across the healthcare community

David: So, you've talked about connecting with other institutions kind of around the country who are kind of all learning real-time. What level of connectivity do you all have with your fellow providers in the area who are part of different corporate entities? Is that done through local and regional public health officials? Are there informal connections? Are there other informal connections? What if any connections kind of exist?

Steve: Yeah, I think that it's multi-channel. And it's almost hard to remember what those are like on an ongoing basis outside of a healthcare crisis. I think part of what we've learned during this pandemic, is where we need to augment that connectivity when we're not in a healthcare crisis, so we're really good when there's a major problem. And so, at its foundational level, there is very close connectivity to and cross-communications to other health systems in the region as relates to county-based health care needs assessments. So we share the commitment to our communities, which is a reflection of county health focuses that go back decades and decades--if not longer. To treating the communities and the health care needs assessments that is driven, collaboratively between the healthcare systems and the county health departments, which allows one method of communicating and aligning on strategies by sharing data, identifying problems, and then committing together to focus from the county as the convener, so that's really important. Through that, there is a regular conversation, collaboration, and alignment.

The next is through shared state level and/or regional level healthcare organizations. The Virginia Hospital and Healthcare Association, VHHA, would be one example. There are several others that are aligned with emergency management, VHAAS, and several other regional, connected both to Federal Emergency Management as well as statewide. The next level then really is starting to get more and more dispersed and diffused into local chapters of national healthcare organizations. And those are everything from the ones that we know right away, which is, you know, Red Cross, for example, would be one that comes to mind where we'll all sit at the same table. And then it gets even more distributed when we start to think of subspecialty. So, a local nurse group and/or the local American College of Surgeons or American Association of Family Practitioners, and so forth, Family Practice.

So, and then finally, how do we interact with other health systems, both regionally and nationally, are through some public, mostly private, organizations that are collaboratives. And those are very broad. However, interestingly, the number of times that I've personally walked into a national health collaborative that might look at progressive health systems or they might distribute it based on size, you actually look across the table, and you're like, "Hey, you're also in the same market I am." So, there's plenty of opportunity. I think most of the real public health components are mostly addressed with the county health departments as the convener.

The spectrum of wellness in primary care

David: One of the learnings from the discussions we've had so far, is that the county-level public health leadership is--what in my old consulting days, we would have called the critical job in public health, which is --the place where it all comes together. Where it either all comes together, or it all falls apart. And we've certainly seen in at the early stages of the pandemic, a huge variety of approaches and attitudes and just sheer velocity, right, in terms of dealing with the issues. There must be a big difference between running a provider--or even practicing in a jurisdiction with forward-looking and kind of aggressive public health leadership--and one where maybe that same description doesn't apply. Have you had direct experience...? Obviously, Northern Virginia is kind of well taken care of in that regard, but either in kind of prior areas of practice or experience, have you seen, that kind of fragmentation and disparity kind of come to life?

Steve: A tough question. That's why we probably all got silent waiting for the other one to answer. I'll pump that a little bit into a broader generalization of some of the gaps that can occur. And most of it, to me is, how do we assure that we remain aligned to the high-level goals? And in those in my experience, where the challenges come is where the expertise and strategic focus areas of a health system may be more specific than the focus areas that the county-level public health, may be. You know, what their priorities are. And I think that that's a reflection of the different lenses. So, if you think about a county-level set of responsibilities, it's very broad. It's from water to policing to, the integrity of business and zoning practices, and public health. So, the lens that is brought there is from that perspective, and I think that that's really important.

And then if you're looking at it from the health care systems point of view, we're thinking about acute care, and the sickest of the sick, and the infrastructure required to deliver that care. And so, I think, my experience has been--and this is not indicative of any one area--is that how do we make sure that the intersection points take that into account? So, we would say that we need to approach obesity as a problem, for example. That's not at least from my perspective, noncontroversial of a public health challenge. So, the approach from a large health system would be along the spectrum of wellness in primary care and medical treatment and risk avoidance, and then management of the obesity through multiple measures, and then treatment of the complications thereof.

From a public health perspective, it would be, what are the access to appropriate foods in a neighborhood or safe access to exercise and green space? And so here you have--once again--the same focus point being on elevated BMI as in obesity, yet, a challenge in that we're each going to see a different part. Take a bite or feel a different part of the elephant. And that's where sometimes, and we all talk about this very openly, the approaches will be different. And sometimes the goals will be slightly different. So, to take that to your question, which is where do we see that that fragmentation, I think that might be a little bit more where we see it, but there's much more alignment than not.

Readiness for a hypothetical surge

David: Well, that's good news. That's good to hear. The last point, and it connects with something that both Maureen and Chapy mentioned, you know, we talked about capacity. The term ‘flat space’ I always find intriguing in the context of a healthcare institution. During the early growth phases of the pandemic, here in Virginia, and different places around the country certainly, capacity was a major concern for planners. And I know that Inova had talked actively with the state of Virginia about increasing capacity. And eventually, the state had set up and then, fortunately, was able to not implement plans to use. Various kinds of public spaces like convention centers, etc., as emergency, you know, locations to expand acute care capacity. What actions did overtake or contemplate, to maximize capacity in the event that it was needed? I mean, fortunately, it turned out it wasn't. But what steps did you all take to kind of plan for such an eventuality?

Maureen: Well, we did look at bed spaces that could be very appropriately used for patient care and areas, for example, in the ambulatory space that was not currently being used for ambulatory patients. And could that space be used and converted into acute care of space. So that was a process that I think all of the health systems in the nation went through to make that determination, you know, where could patients be appropriately and safely cared for? And then what would the staffing needs be to be able to meet the demand of the patient volume? And so that was work that was done across Inova. In some cases, and I had mentioned previously, about expanding the ability to have negative pressure to reduce the risk of spreading of the droplets or the aerosolization for the patients who had the COVID infection. And so, we did expand our non-negative pressure rooms into the creation of additional negative pressure rooms, which also did impact our ability to extend care and to extend our critical care beds. Because that's where we really saw the need to be able to expand care for these patients.

Chapy: The only other thing that I would add on top of that is it did also cause us to come together as a system really quickly to understand across the system, rather than at each hospital itself, where all the patients were, where are the surges happening, and how can we adapt accordingly through a daily capacity management call on the system level. Which I think was a pretty cool innovation that will definitely endure after COVID has gone. In another example that was pretty interesting for me to learn from was, we do have a post-acute care facility, Loudoun Nursing and Rehabilitation Center. And we realized there were a lot of patients who are ready to be released from acute care, yet did not have aa post-acute care to go to. And actually, there was--as Maureen had talked about--some space being unused on the campus of Loudon Hospital that was able to be temporarily repurposed into a post-acute care setting where we were able to move those patients for them to be cared at the right level of care. So that we could actually have our staffing in the acute care setting be dedicated towards taking care of those, the sickest of the sick. That was just one example of how I think we were pretty adaptable during the pandemic to meet the needs of our community.

David: And then the last question I have before we wrap it up is, Maureen talked about staffing. I know from other conversations in the podcast series that this issue of kind of rapid credentialing has been an important part of the response to the pandemic. Can you just say a few words just about how Inova has kind of participated in that whole kind of flex of the system in terms of providing rapid credentialing to providers that historically might have taken a longer time? Because from my own involvement, the credentialing process I know how involved it is under normal circumstances.

Steve: Yeah, I'm happy to take this one, David. We first and foremost started with, as Chapy mentioned, a very clear data-driven approach to capacity management on the team member side. And--as you allude to--on the physician practice side there's a requirement and for a governance process that assures appropriate, safe, licensed professionals. Now we're just focusing on the physicians can gain privileges through a credentialing process to provide that care. There are a couple of things that were put in place progressively at Inova over the last year or so, which has been a more decided approach to sort of baseline privileging that can be shared amongst the different hospitals, particularly, knowing that in today's world the general governance still holds roots at each care delivery site. And that's a combination of regulatory requirements and governance requirements. So first, identify the need.

The second is to identify where the sources of practitioners are. It was pretty darn phenomenal during the early parts of the COVID-19 pandemic the number of individuals who rose to action and volunteered far out-exceeded our need. Now, we didn't know that at the time but those who had not had privileges before--those that had reduced their privileges because of change in practice or retirement, cross-privileging, cross-credentialing. So that was a requirement. All of us have trained in different realms, and that expands from both nursing and physicians at some point in our career. So, we wanted to leverage that experience if needed. And the combined understanding that we really could only succeed by thinking like a system and putting away the thoughts of well, what makes us different at any acute care site or care delivery site as opposed to a philosophy which was really heartwarming to say, "How can we be more alike?" So, as you may be aware, our process allows for governance at the system level for the ultimate approval of privileging. So, we initiated that and put in place, and expedited what I believe is a no less safe system.

Now, the only caveat to that is that we were working on time pressure. It really just caused us to speed up our normal processes and be moderately liberal, not in a less safe environment, but in prioritizing individuals based on where they've been. For example, we know that there are some who have privileges at one of our care delivery sites and not another. That was almost an easy one. Since we're one system we said, "Okay, these individuals can now go between site-to-site." So that required almost no process, just approval. And then there are some who are, "Well, I'm a surgeon at one site, or an advanced practitioner at one site, focusing on surgery, but I can also help in critical care doing certain duties." So that was sort of the next one that like skills but still in the system.

And then the last one was shoring up our background team to run individuals through the process quicker, and in a more consolidated fashion. And what we found was that we were able to get the help we needed, that we didn't need to go as deep as we thought we need to go. And really, as the privileging credentialing has dropped off as the need has dropped off, we really haven't run into any issues as of right now. So that's kind of long-winded, but it's been a real success story, I think, particularly for Inova.

David: Yeah, and I think the lesson from so many of these different attributes is that there are things that you only are really forced to learn during an exceptional period of stress and anxiety and extra effort that-- hopefully--we can maintain as part of the system going forward. I really want to thank my three guests, Steve, Chapy, Maureen, for joining us here and giving us a window into how the Inova Health System has been viewing some of these critical challenges during this most interesting year of 2020. And for giving us some insight into how they support the broader extended public health enterprise, which is the topic we've been talking to everybody about. My thanks to all three of you. And with that, I think we will wrap it up for this week. Take care, everybody.