Transformational Leadership A Pathway for Governance · A Pathway for Governance Todd Linden, FACHE ... • Transitioning to value-based reimbursement ... • Drive toward patient-centered

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Transformational LeadershipA Pathway for Governance

Todd Linden, FACHEPresident and CEO

Grinnell Regional Medical Center

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The Motorcycle Administrators

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Presentation Overview

• Setting the Stage – What’s Driving the Transformation

• Rural Challenges and Concerns

• Positioning for Success

• Hospital CEO for 25 years

• Raised in a Rural Hospital Family

• American Hospital Association Board of Trustees 2000-05

• Nat’l Advisory Committee for Rural HHS 2008-11

• Current Boards:

• Health Forum (AHA)

• Grinnell College

• University of Iowa College of Public Health

• Faculty:

• American College of Healthcare Executives

• University of Iowa

• Testified multiple times for US Congress

My Background

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We Are a Tweener!

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“Go West Young Man, Go West”

Home to Grinnell College

First Prepaid Health Plan 1921

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Rural Hospital Issues and Challenges

Survey Summary

Most Dominant Challenges:

• Improving financial strength (14%)

• Increasing growth & market share (9%)

• Coping with unknowns of reform (8%)

• Building physician alignment & loyalty (8%)

• Improving quality & patient safety (8%)

» The Walker Company


Survey Summary

Accomplishments to Achieve:

• Improve cost efficiency (21%)

• Develop new services (15%)

• Enhance physician relationships (14%)

• Improve patient customer service (14%)


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Survey Summary

Governance Expertise Required:

“83% of CHA members believe the challenges will require greater expertise and effectiveness.



Survey Summary

Greatest Board Value:

• Strong community representation & dedication to the community

• Commitment, loyalty & support for the organization’s success

• Willingness to work together

• Flexibility & adaptability


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Survey Summary

Factors Critical to Governing Success:• Trustees who are well-educated about the

challenges & issues that will most affect the hospital’s success (35%)

• The ability to lead through uncertainty & change (25%)

• Trustees well-educated about & adhere to their governance responsibilities (17%)

• Ability to successfully adapt to reform (10%)

• Macro-leaders and not micro-leaders (8%)

Concerns for Rural Providers

• CBO: Eliminate alternative hospital designations:

– Critical Access Hospital– Sole Community Provider– Medicare Dependent Hospital(Endorsed by Ways & Means Democratic Staff)

– Total cut to rural facilities over 10 years:• $62.2 Billion

Adapted from Alan Morgan, CEO National Rural Health Association

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• President Obama: – End add-on payments for docs and hospitals

in frontier states

– Reduce CAH reimbursement to 100% of cost

– End CAH reimbursement for hospitals located 10 miles or less from another hospital.

– Cut to rural facilities over 10 years:

• $6 Billion


• House Republican Leadership: – Cut $2 billion from frontier state add-on

payments

– Cut $14 billion from rural hospital reimbursement structures


• $16 Billion

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• Sequestration cuts: – Super Committee failed to produce savings

and therefore an automatic cut of two percent is instituted for all providers.


• $5.9 Billion


• Critical Access Hospitals: – Medicare and Medicaid– Created in 1997 to prevent rural hospital

closures (360 hospitals closed in 1980-90s)– 101% cost reimbursed– 41% CAH operate at a financial loss today

• Cost Based Payment is not consistent with where reform is going…– Does not necessarily incent low cost or high

quality

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Factors Driving the Change

• Shifting demographics of patients and workforce

• Transitioning to value-based reimbursement

• Needing to eliminate care fragmentation

• Increasing transparency of cost and quality data

• Continuous advances in technology

• Challenging variations in care

• Increasing the speed of adoption

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Among Medicare Beneficiaries Enrolled in Managed Care Plans, African Americans Receive Poorer Quality of

Care (Schneider et al., JAMA, March 13, 2002

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30

40

50

60

70

80

Per

cent

Rec

eivi

ng S

ervi

ces

BreastScreening

Eye Exams BetaBlockers

Follow-up

Health Service

WhitesBlacks

“The First Law of Improvement”

Every system is perfectly designed to achieve

exactly the results it gets.

1,000,000

100,000

10,000

1000

100

10

1

DEFECTS 50% 31% 7% 1% 0.02% 0.0003%SIGMA 1 2 3 4 5 6

PPM

• Low Back TX

•Post Heart

AttackMedications

•Mammography Screening

• IRS - Tax Advice(phone-in) (140,000 PPM)•

Inpatient Medication Accuracy

• Airline Baggage Handling

•

Domestic Airline Flight Fatality Rate (0.43 PPM)

Sigma Scale of Measure

Difficulty with Referral

•

American health care

"gets it right“

54.9%of the time.

McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348(26):2635-45 (June 26).

The Healthcare Full Monty

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“ What is Common Sense?

That sense which is not commonly applied! ”

- Mark Twain

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Over-Utilization

Guess the following number: How many doctors are involved in the care of a

single Medicare patient, on average, in the last 6 months of life, at New York University Medical Center? (i.e. How many doctors are billing for care of one patient in 6 months?)

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Source: New York Times, November 3, 2009

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$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

Australia

Canada

France

Germany

United Kingdom

United States

Comparative Health Care Spending per Capita

Sources: The Commonwealth Fund, calculated from OECD Health Data 2006, Global Health Facts, 2011.

Adjusted for Cost of Living – U.S. Costs are More and Rising Faster

Obama Health Reform Efforts

11 million new kids and

pregnant moms

CHIP Reauthorization

Feb. 4, 2009

FMAPHIT

Comparative Effectiveness

Wellness

American Recovery and Reinvestment

Act

Feb. 17, 2009

32 million more covered

Insurance reformsIndividual mandate

Insurance exchangeAdministrative simplificationProvider cuts

Quality initiativesNew delivery modelsWellness initiatives

New taxesProgram integrity

Affordable Care Act

March 23, 2010

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It’s the law - March 23, 2010

Let me get this straight. We're going to be "gifted" witha health care plan we are forced to purchase and fined (taxed) if we don't, written by a committee whose chairmasays he doesn't understand it, passed by a Congress thathasn't read it but exempts themselves from it, to be signed by a president who also smokes, with fundingadministered by a treasury chief who didn't pay his taxes, to be overseen by a surgeongeneral who is obese, and financed by acountry that's broke.

What could possibly go wrong?

Maxine on Healthcare Reform

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Additions to ACHE slide deck

The Goal: The Triple Aim

Experience of Care

Population Health

Per Capita Cost

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High Triple Aim Goals

• Improved Health of the Population: The best local & national health outcomes, the healthiest communities, and patients who are the most engaged and accepting of personal accountability

• Enhanced Patient Quality/Experience: The best performance on customers’ willingness to recommend our clinics, hospitals and partnered health plans to family & friends

• Reduced per Capita Cost of Care: Cost trends that are at or below general inflation; the best performing overall health care costs in the region

Future Health Care Economic Model

Pay for Perform-

ance• Cost• Quality• Access• Service

Bundled Payments

• Individuals’ Care Across Settings

Fee for Service

Global Payments• Discreet

Popula-tions

• Disease based

“Own” the Lives

• Shared Savings

• Capitation

Treatment-Based Episode-Based

Population-Based

Today: Paid for Volume•Maximize Clinical Operations•Highly Effective Delivery System

Soon: Paid for Events

•Assume Performance Risk•Integrated Healthcare Delivery

Tomorrow: Paid for Lives•Manage Population Health•Insurance Risk Capable

Health Care Reform – Shifting Risk to Providers

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How does an ACO work?

Whitewater Changes Are Happening Now and Accelerate Transition To Value-Based Revenue Model!

2013 – 2015 WHITEWATER CHANGE

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• Declining Utilization• Reduced Payment• Physician Disruption• Declining Profitability• Significant New Capital Investments: IT &

Accountable Care

NEW MODEL REQUIRES A COMPLETE REDESIGN OF HOW HEALTH CARE IS ORGANIZED, MANAGED & DELIVERED

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Scoring Hospitals’ VBP Performance• Hospitals will receive the higher of their attainment or

improvement score on each measure

• Score on each domain equals points earned out of total possible points

• FY 2013 payment based on:

FY 2014 payment based on:

HCAHPS 30% Process 70%

Efficiency20%HCAHPS 30% Outcomes 30%

Process 20%

Hospital-Acquired Conditions

Beginning in FY 2015, adds a 1 percent penalty to hospitals in the top quartile of rates of Hospital-Acquired Conditions, resulting in reductions of $1.5 billion over 10 years

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Health Insurance Exchanges“Why They Matter to Providers”

• Potential to shift the nature of the health care transaction

• Rapid transition from Defined Benefit Pensions to Defined Contribution Benefit Pensions should be seen as a precedent and likely bellwether

• At the low end, roughly 10% of the population. At the upper end, 50% + of the population eventually involved

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And then of course…the REGS!

• RAC Audits

• Two Mid-night Rule

• 96 Hour Rule

• Outpatient Supervision

• Etc. Etc. Etc.

Medicare• Payment cuts for poor patient satisfaction (now)• Payment cuts for poor quality (soon)• Bundled payments and “ ACO” payment models (now)

Commercial Insurers• Pilot programs implemented• Increasing pre-certification requirements and denials• Interest in permanent changes to payment systems

Large employers• Direct contracting for preferred providers for selected

services (Lowe’s contract with Cleveland Clinic for open heart surgery)

• Interest in relationships with providers for improving employees’ health and reducing insurance costs

Ready or Not… Paying For Value is Here

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• Changed Care: focus on population health, care management, improved outcomes

• Changed Payment: pay for value not volume, more economic risk for providers

• Changed Experience: more engaged patients, increased consumerism

Adapted From: Health Care Advisory Board “Accountable Care Playbook” 2011

Summary of the “New Normal”Under an Accountable Health Network Model:

So is the New Law…

YES

Good? Bad?or

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Winston Churchill, November 10, 1942 at the Lord Mayor's Luncheon at Mansion House in

London, in response to the Allied victory at the Second Battle of El Alamein.

This is not the end. It is not even the beginning

of the end. But it is, perhaps, the end of the

beginning.

Health Reform Implementation…

Hospitals will need tobe:

More Integrated

More Accountable

More At-Risk

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Implications for Rural Community Health Systems

• Need to be a part of systems involved in the new payment systems (shared savings, risk) or lose volumes to those who are;

• Rural providers may be MORE important than ever in the health system: lowest cost setting of care, ability to engage patients and providers, ability to impact health status;

• Drive toward patient-centered medical homes represents an opportunity for rural providers – its what we already do!

Implications for Rural Community Health Systems

• Physician shortages—will become even more difficult

• IT requirements and costs—high and getting higher

• Sharing risks with new entities we don’t control

• Ability to DEMONSTRATE high quality and low costs, in order to be included in the system of care

• Complex Organizational and legal structures

Challenges:

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Transformational Leadership Habits• Driven by Strong and Focused Sense of

Purpose

• Leadership Directed Up, Across, Down and Out

• Ethic of Deep Decisive Dialogue that Matters

• Focus on Transparency Where It Counts

• Continual Community Centeredness and Connectedness

• Fiduciary Fitness

• Governance Growth and Development» The Walker Company

“When you come to a fork in the road, take it!”

Yogi Berra

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1. Driven by Strong & Focused Sense of Purpose

• Mission, Values, Vision

• Strategic Thinking

• Governance Processes

• Ethics and Values

• Different Scenarios

• Focus on the Emergent

• Innovation

• Execution» The Walker Company

www.siib.org

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Art Advisory Committee

An organization dedicated to helping hospitals improve the environment and save money by sharing best practices in promoting Green behaviors.www.practicegreenhealth.org

Practice Green Health

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Current Modalities Offered• Acupuncture• Aromatherapy• Biofeedback• Cranioscral Therapy• Visceral Manipulation• Healing Touch• Massage Therapies• Therapeutic Body Wraps• Paraffin Treatments• Chiropractics

• Meditation• Nutrition Counseling• Exercise/Personal Coaching• Children’s Fitness Programs• Reflexology/Stress Mgmt• Guided Imagery• Ear Candling• Music Therapy• Pet Therapy• Music Therapy

• Chemo• Hospice• Inpatient Med/Surg• Intensive Care• Obstetrics• Surgery

Blending with Traditional Services

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Pre-Op Massage Outcomes• Length of waiting time perceived

shorter• Decreased anxiety levels• Improved anesthesia results• Ease of IV Insertion• Reduced use of medication used pre-

operatively to cope with anxiety, results in shorter recovery time.

Patient Satisfaction

• “The massage was a wonderful surprise and really helped with my anxiety level before both my surgeries.”

• “The best thing about my hospital stay was the massage therapist.”

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Pet Therapy

“Since both in importance and time, health precedes disease, so we ought to consider first how health may best be preserved, and then how one may best cure disease”

– Galen (C.170 AD)

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Fitness Center

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Transforming Stress Workshop

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Quick Coherence® Technique

Heart focusHeart breathingHeart feeling

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HeartMath Website: www.heartmath.org

2. Transformational Leadership

• CEO Performance Motivation

• Workplace Culture

• Medical Staff Alignment

• Advocacy

»The Walker Company

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“Our way to create and enhance a service excellence journey to build patient loyalty, promote teamwork and celebrate the joy of caring.”

Compassion in Action

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Engaging the Medical Staff

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Medical Staff Synergy

• Board of Director Advance• Joint Board/MS Meetings (4/yr)• Integrated Health and Hospice• Social Events• Bicycle Helmet Give Away• Board/Med Staff Task Forces

– Recruitment– Communication– Process Improvement– Info Technology– $500K Committee

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Trustees Make Powerful Advocates

–Represent the community

–Typically are volunteers

–Can tell moving stories

–Can bring great influence

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3. Ethic of Deep, Decisive Dialogue that Matters

• Artful Listening

• Critical Conversations

• Constructive Confrontation

• Disparate Voices

• Rapid Cognition

• Pattern Recognition»The Walker Company

Eliminating Harm, Improving Patient CareA Trustee Guide (Handout)

• Role of Board in Quality Improvement

• Effective in Eliminating Harm

• Alignment of Safety/Quality with Financial Performance

• Collect and Review Meaningful Data

• Measuring Harm

• Organizational Approach

• Clinician Engagement

• Strong Quality Culture

• Patient and Family Engagement

• Diversity in the Boardroom

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4. Focus on Transparency Where it Counts

• Pricing

• Quality

• Governance


Board Orientation

“Even if you are on the right

track, you’ll get run over if you just sit there.”

- Will Rogers

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5. Continual Community Centeredness and Connectedness

• Public Trust

• Community Needs

• Benefit and Value


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Community Engaged• Board of Directors

• Foundation Board

• Auxiliary Board

• Patient and Family Care Council

• Advisory Committees:– Arts

– Hospice

– Home Healthcare

– Senior Education

Patient & Family Care Council

• 10-15 Community Members

• Meets Bi-Monthly

• Reviews– Policies

– New Programs

– Construction Projects

– Performance Measures

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6. Fiduciary Fitness

• Duty of Care

• Duty of Loyalty

• Duty of Obedience


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• Obtain necessary and adequate information before making a decision

• Act in good faith

• Make decisions in the best interest of the hospital

• Set aside personal interests


Duty of Care

• Objective and unbiased

• Free from external control and without ulterior motives

• Free from conflict of interest

• Able to observe total confidentiality when dealing with hospital issues


Duty of Loyalty

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• Develop code of ethics and whistleblower policies

• Adopt and monitor specific fundraising policies

• Carefully outline and determine compensation practices

• Develop and strictly adhere to document retention policies


Duty of Obedience

7. Governance Growth and Development

• Education vs. Knowledge and Intelligence

• Investment in Knowledge Capital

• Succession Planning

• Governing Performance Self-assessment

• Governance Peer Review » The Walker Company

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The Trustee Organization and Education Committee (TOE)

• Annual Assessment

• Develops Annual Education Plan

• Encourages Board Certification

• Analyzes and Vets Board Nominations

• Maintains Board Succession Plan

• Created Board Orientation

• Developed Code of Conduct Policy»Hand out

Positioning for Success

Must Focus on:

• Quality

• Safety

• Costs

• Experience

• Special Focus on Integration

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What can a Critical Access Hospital Do?

• Develop a partnership with an ACO to learn new care delivery and to participate in insurance contracts.

• Share data to learn your metrics and improve them.

• Lower costs – both cost per unit and episode of care.

• Focus on quality outcomes and cost - And data to prove it.

• Develop a strong primary care base – this is where ACO patients will come from.

• Develop continuum of care services – home care, SNF.

• Devote resources to work through the transition.

--Coaches --Data Warehouse.

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So What’s This All Mean?

Find a way to organize ourselves into an approach that delivers

on the Triple Aim

1. Improved Health of the Population

2. Enhanced Patient Quality/Experience

3. Reduced per Capita Cost of Care

Your Hospital’s Path to the Second Curve: Integration and Transformation

2013 AHA Committee on Research

January 2014

© 2014 Health Research & Educational Trust

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Your Hospital’s Path to the Second Curve

The 2013 Committee on Research report serves as: • A call to action for hospitals and

care systems to transform into organizations that provide better, more efficient and integrated care for patients and populations.

• A guide for hospitals and care systems to successfully navigate the changing environment

The report provides:• A strategy map with must-do

strategies to implement, organizational capabilities to master, top strategic questions to answer and five potential paths to identify and consider

Your Hospital’s Path to the Second-Curve Framework

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Hospitals and Care Systems of the Future

– Must-do strategies to be adopted by all hospitals

Second curve metrics measure success of the implemented strategies

–Organizational core competenciesthat should be mastered

Self-assessment questions to understand how well the competencies have been achieved

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First Curve to Second Curve Markets

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First Curve to Second Curve

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First Curve to Second Curve

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Must Do Strategies and Core Competencies

1. Clinician-hospital alignment

2. Quality and patient safety

3. Efficiency through productivity and financial management

4. Integrated information systems

5. Integrated provider networks

6. Engaged employees & physicians

7. Strengthening finances

8. Payer-provider partnerships

9. Scenario-based planning

10. Population health improvement

Organizational culture enables strategy execution

1. Design and implementation of patient-centered, integrated care

2. Creation of accountable governance & leadership

3. Strategic planning in an unstable environment

4. Internal & external collaboration

5. Financial stewardship and enterprise risk management

6. Engagement of employees’ full potential

7. Utilization of electronic data for performance improvement

Development of Core Competencies

Adoption of Must-Do Strategies

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ANSWER Top 10 Strategic Questions

1.What are the primary community health needs?2.What are the long-term financial and clinical goals for the organization?3.Would the organization be included in a narrow/preferred network by a health insurer based on cost and quality outcomes?4.Is there a healthy physician-hospital organization?5.How much financial risk is the organization willing or able to take?

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ANSWER Top 10 Strategic Questions

6. What sustainable factors differentiate the organization from current and future competitors?7. Are the organization’s data systems robust enough to provide actionable information for clinical decision making?8. Does the organization have sufficient capital to test and implement new payment and care delivery models9. Does the organization have strong capabilities to deliver team-based, integrated care?10. Is the organization proficient in program implementation and quality improvement?

IDENTIFY Potential Paths

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Five Potential Paths

Redefine to a different care delivery system (i.e., either more ambulatory or oriented toward long-term care)

Partner with a care delivery system or health plan for greater horizontal or vertical reach, efficiency and resources for at-risk contacting (i.e., through a strategic alliance, merger or acquisition)

Integrate by developing a health insurance function and/or services across the continuum of care (e.g., behavioral health, home health, post-acute care, long-term care, ambulatory care)

Experiment with new payment and care delivery models (e.g. bundled payment, accountable care organization, medical home)

Specialize to become a high-performing and essential provider (e.g., children’s hospital, rehabilitation center)

Guiding QuestionsHospital and care systems must conduct an honest assessment of organizational goals and needs, current capabilities and capacities and the ability to support and sustain any transformation. Examples of guiding questions that facilitate change across multiple dimensions are:

• What does the hospital or care system want to achieve in the long term for care delivery and operational performance?

• What is the impact of national health care reform on the organization?

• Who are the current and future competitors and how are they evolving?

• What other community organizations can the hospital or care system collaborate with?

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Guiding Questions

• What are the current and projected sources of revenue, profitability and cash flow, and how are these projected to change over time?

• Is the organization’s workforce team oriented with a demonstrated history of collegial relationships?

• Are the current facilities designed for the future in terms of expansion or reconfiguration for different services?

• How much risk is the organization willing to take? • What are the organization’s measurable milestones

for the next one to three to five years?

Factors Influencing Path Progression

Factors that influence how soon and how quickly hospitals and care systems can select a path and move forward:

• Changing payment system• Degree of physician alignment• Health care needs of the community• Purchasers moving to new models• Providers in the market moving to new models

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© 2014 Health Research & Educational Trust

Resources to Accelerate Organizational Transformation

AHA ResourcesHospitals in Pursuit of Excellence_______________________________________________________________________________________________

AHA GuidesHospitals and Care Systems of the FutureMetrics for the Second Curve of Health CareSecond Curve Road Map for Health CareAHA Research Synthesis Report: Accountable Care OrganizationsAHA Research Synthesis Report: Patient-Centered Medical HomeAHA Research Synthesis Report: Bundled PaymentAccountable Care Organizations: An AHA Research Synthesis ReportA Guide to Strategic Cost Transformation in Hospitals and Health Systems_______________________________________________________________________________________________

Other ResourcesH&HN Daily: Making the Leap to Value

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Clinically Integrated Organization

• Clinical Integration Legal (FTC) Definition:“…an active and ongoing program to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality.” It is not capitation and it is not the messenger model of the past.

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Clinically Integrated Organization

• Our Definition: “Aligning physicians, hospitals, and other providers to improve quality, safety and efficiency, and to contract effectively in order to compensate providers for value created. CI is not an end, in and of itself. Its purpose is to position us for success in the management of population health and to sustain the viability of our mission.”

Sharing and Integration

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MHN STRATEGY: AGGRESSIVE MOVE TO VALUE-BASED PAYMENT

Optimize Value & Share of the Insurance Premium Dollar

Possible Grinnell – Clinically Integrated Organization – Relationships

Clinically Integrated Organization – (CIO, LLC)Single or Multi-Member Subsidiary of GRMC-- Could include physician & other hospital

owners; Physician-led

GRMC Employed Physicians/Mid levels

Post Acute Care Facilities

Other Healthcare Providers

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Independent Practices

Provider Clinical Integration Agreements

Developed initially as GRMC

Subsidiary—has the ability to

change into Joint Venture

Grinnell IntegratedLeadership Structure

Grinnell Health New Corp.

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Structures: Develop State-Wide MHN & Regional Clinically Integrated Network Structures

Sioux City CIN: 50/50

JV

North Iowa CIN: Single

Member LLC

CHI Central Iowa CIN:

Single Member LLC

Clinton CIN: Single

Member LLC

Dubuque CIN:

Existing JV

Grinnell CIN: Single

MemberLLC

Catholic HealthInitiatives-Iowa

CHE-Trinity Health-Iowa

Mercy Health Network

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MHN Clinically Integrated Network

Legal WaiversScale: ACO Financial ReturnScale: Shared Infrastructure

Performance StandardsPlanning/ Timing/ ContractingJoint Trinity/CHI Governance

Go to Market Strategies / Product

Offerings

University of Iowa Healthcare Alliance Structure

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Other Potential Members

Mercy Health

Network

Mercy Cedar Rapids

Genesis Health System

UI Health Care

Network Board and Management

Member Sub-Agreements

Primary Care Development/

Care Coordination

Insurance Initiatives /

Relationships

ACSSO(Accountable Care / Shared

Services

Specialist Relationships

Medicare ACO

Integrate Ancillary / Treatment

Services

Clinical Services

Ambu-latory

Services

Home Care

New Technol-ogies /

Innovation Businesses

Required Components of Network Membership

Research & education

Tele-health

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Initial Alliance Members/Affiliates

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1 University of Iowa Hospitals & Clinics11 MHN Hospitals1 Mercy Cedar Rapids4 Genesis Health System Hospitals30 Rural Affiliated Hospitals MHN Affiliates

The Goal: The Triple Aim

Experience of Care

Population Health

Per Capita Cost

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Acknowledgments

• John Combes, MD – American Hospital Association

• Joanna Kim– American Hospital Association

• David Vellinga - Joe LeValley– Mercy Medical Center – Des Moines

• Keith Mueller, PH.D.– University of Iowa College of Public Health

• Alan Morgan – National Rural Health Association

• SSB Solutions

• Maulik S. Joshi, Dr.P.H.-- HRET

• Association Hospital and Health Systems – January 2011

Documents

Transformational Leadership A Pathway for Governance · A Pathway for Governance Todd Linden, FACHE ... • Transitioning to value-based reimbursement ... • Drive toward patient-centered