Episode 21: Looking Toward the Future: Part 3

The business of health care faces a multitude of challenges to rein in costs while improving on and delivering safe, high-quality care. How can improved safety and reducing avoidable hospitalizations play in the economic landscape for health systems? Join host Karen Wolk Feinstein and health system CEO and futurist Josh Luke for a compelling conversation on the keys to changing the status quo and bolstering the industry for a stronger future.

Listen to this episode on: Apple Podcasts | Spotify | Health Podcast Network

Featured Speakers

Referenced Resources (in order of appearance)

Episode Transcript

[00:00:00] Josh Luke: Our elected officials need to recognize that the second largest expense in any business and in a lot of homes is health care. It is just going to take some real bravery on behalf of the federal government to ratchet in what’s become a system beyond control. I don’t know if it can be done at the state level. It needs to be done at the federal level.

[00:00:26] Karen Wolk Feinstein: Welcome to Up Next for Patient Safety. We continue conversations with the most interesting people doing important work toward our common goal of making health care safer, but also more reliable and even more satisfying for both patients and practitioners.

I’m your host, Karen Feinstein, President and CEO of the Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative, which is a multi-stakeholder quality collaborative located here in my hometown, but with statewide, national, and even global links. We have been working to reduce medical error for 25 years, and I will say, we never believed progress would be this slow.

I do know that revolutions come from hope and not despair. I’ve found that these conversations inspire me with hope as we hear from safety leaders of distinction. This episode is part of a three-part series on the future of health care. We’ll be joined by some notable futurists, who will share their insights on where health care is heading and how to ensure that patient safety will be part of this future.

Given the challenges facing health care today, many exacerbated by the pandemic, even if longstanding, we wanted to hear where these experts envision the industry moving toward a safer, more trustworthy future.

In today’s episode, we’ll dig into some of the critical challenges facing the business of health care with Dr. Josh Luke, an expert who’s had an insider’s view into the industry and has something to say about how to make health care better while controlling costs. We’ll also delve into one of the key drivers of both increased costs and poor patient outcomes, that is, avoidable hospitalizations. Dr. Luke has been CEO of four hospitals and is currently the CEO of North Kern South Tulare Hospital District in California. He has also previously founded the National Readmission Prevention Collaborative. Josh is a leading healthcare futurist, a Forbes contributor, and faculty for the University of Southern California’s Sol Price School of Public Policy. He served as CEO of an acute rehab hospital, as a nursing home administrator, and as vice president of post-acute services for a health system, where he oversaw home health and hospice services.

He’s also authored several books, including Readmission Prevention: Solutions Across the Provider Continuum, Ex-Acute: A Former Hospital CEO Tells All on What’s Wrong with American Health Care, and most recently, Health Wealth: Nine Steps to Financial Recovery. So, welcome Josh. These are provocative titles. I can’t wait to get going.

[00:03:28] Josh Luke: Every time I hear that, I am just reminded that I obviously can’t keep a job for very long. So, I appreciate you having me and just sharing that diverse background in health care.

[00:03:38 Karen Wolk Feinstein: I can’t wait to read Ex-Acute. So given the triple afflictions, and that they are all interconnected, facing health care now, I think: one is workforce burnout, the low morale that exits among our current workforce; second, the rise in medical errors, and the third, growing public mistrust, give me one or two solutions you think would make a difference, and then tell me what is the likelihood that our health systems will put them in place.

[00:04:09] Josh Luke: Yeah, great question. I think if I were to name two things, I think transparency on behalf of the hospitals and health systems as it relates to pricing transparency. We’re three or four years into a battle now of being required to post prices online so people can shop like they do for every other thing in our country, but it’s been kind of a moving the cheese contest to just listing it in a way that’s even more confusing than a regular person could understand. And so, I just think the government’s gonna have to stay on that until it’s something that the public can understand and that would be number one, transparent.

I think number two would just be the government getting more involved in price controls. I’m a capitalist, like most people are. I’m very pro capitalistic society. But the reality is insurance companies raise their costs because hospitals raise their costs, and everybody wins. And pharmaceuticals raise their costs, and it’s being passed on to corporate America and to the families, the employers, it’s interesting, growing up in the ’80s as a Gen X-er and even in the ’90s you’d hear, “Oh, I have employer-based health care or commercial health plan, so I hardly pay anything.” Well, you don’t hear that statement anymore because every paycheck for a family, it’s $500 or $600 coming out of their paycheck for their employee share, and so sooner or later some of these CFOs are going to have to be bold enough to say enough is enough and really just take control over their healthcare spending just like they would every other budget line item in their company. And you see a lot of these direct contracting deals popping up between health systems and employers, and I think you are going to see a lot more of that, if you wanted a third tactic there.

[00:05:58] Karen Wolk Feinstein: I have often wondered why employers don’t speak up—why employers who also have lobbyists and who also have influence at policymaking levels, why they’re not more outspoken on this topic of price controls. You know, what seems so obvious is that the patients and the employers by now would have risen up and said, “We have got to stop this mayhem.

Let me go to reducing readmissions—one of your areas of focus. There has even been some concern about whether a focus on reducing readmissions might have gone too far. We might be keeping people out of a hospital to keep our readmission rates down when they needed to be readmitted. Talk a little bit about the most current perspective you have on reducing readmissions as a key to better outcomes of care.

[00:07:04] Josh Luke: Yeah, great question. And when we founded the National Readmission Prevention Collaborative back in 2013, it was still a new topic that most people hadn’t heard about. It was introduced with Obamacare, the Patient Protection Affordable Care Act of 2010. We founded our not-for-profit—you can still find that website at nationalreadmissionprevention.com if you want to learn more. When we founded that, we knew so little about it. But what we learned so quickly is that the readmission penalty, the hospital readmission penalty, is intended to be punitive.

After years of what those in the industry know to be called fee-for-service reimbursement, where Medicare or a company or an individual pays a fee for a service, a physician service, a hospital service and nursing home service. It is basically a per diem. During that model, all the incentives for hospitals, for doctors, for nursing homes, for home health providers was just to run the score up to give as much care as possible and build, build, build. And we did that.

What the government did in the Affordable Care Act was put in a series of checks and balances to make sure that people weren’t abusing that, and one of those checks and balances is called the hospital readmission penalty. So, it is intended to be punitive and it basically said if people return to the hospital within 30 days of discharge, the hospital that originally discharged them is going to be penalized financially because we’re going to assume they could have done a better job caring for them the first time they were there. So just on the surface it appears to be punitive because it is. So, that’s number one. But what I really liked about your line of questioning is that you are among the groups that have figured out that this is really about admission prevention, not readmission prevention.

And what that means is, the Affordable Care Act and the checks and balances that were put in place, and there’s multiple, five or six of them at the time, were to make sure that we’re not overutilizing, and that’s a healthcare term for if a patient does not need to be in an acute hospital and can be cared for at a lower level of care, well then do not admit them to the hospital because the prior method, fee for service, as we described, was not designed that way. It was designed to say, “Oh, you admitted them. We will pay you whether or not they need it or not.” All these checks and balances were just a way of really saying, pushing it down a little bit. Do not over-admit when you don’t need to admit.

[00:09:40] Karen Wolk Feinstein: I’m very sympathetic to that. But one thing that readmission reduction and admission reduction requires is a strong network of primary care and skilled nursing and other institutional services in the community that are prepared to do interventions that prevent people arriving at the hospital and the ER, and, you know, right now, I’m very disappointed at how little energy we’re putting into building a strong fabric of primary care, even though we know that it’s fraying.

And skilled nursing is another interesting issue. We had a big CMS grant to reduce readmissions from nursing homes, and hospitalizations. It was so successful, we were one of the CMMI grants that got renewed. It wasn’t that hard to do, but then again, you know, the funding for it, the staffing that you need at the skilled nursing, or any, the personal care level, what you need in terms of an adequate primary care network, I don’t see much attention being given to that.

[00:10:57] Josh Luke: Yeah, I think your observations are right on, and congratulations about having that CMMI grant, Center for Medicare and Medicaid Innovation for those of you who may not know, was really the first time the Feds came out and said, “Hey, we’re going to recognize that you as providers probably know better than we do. So why don’t we let you make the rules and design some delivery models for once, and we’ll put aside some money to pay you to do that?” Thank goodness they did because we learned so much. And what came to mind as you asked me that question, first, you asked about skilled nursing. What can they do to help prevent avoidable hospitalizations?

The simple answer is, communicate proactively with the hospital. It also serves as a marketing opportunity to just open doors and get more referrals from the hospital. If somebody is going back to the hospital, don’t hide from it and pretend like the hospital is not going to notice. Call and say, “Hey, we’ve done everything we can because we’re looking out for you and for this patient, we don’t know that this patient needs to be admitted to the hospital, but we tried everything on our end, and they are coming back to the ED. So, let us know what we can do. We didn’t have the capability over here to rule out some things and you guys do, so don’t assume they need to be admitted, but give us a call and let us know how it works out, because we’re working for you to prevent avoidable admissions.”

Number two, the second part of your question is about hospital readmissions and how to prevent avoidable hospitalizations for hospitals, not nursing homes. It’s just to reprogram your emergency department. Emergency department doctors are programmed to think that they are there to justify admitting patients who show up at the emergency room. And not only has that been proven, because that was the model for so long, but we also learned that patients, when they call 911, expect to be taken to the hospital. And we learned that because some of these CMMI pilot programs across the country where paramedics finally had the opportunity—I don’t know if you’ve noticed, folks, but paramedics don’t give care in the field. They put you in a gurney and take you to the hospital. They really were discouraged from and not allowed to give care in most cases but just to get you quickly to the nearest emergency department. Well, there are some programs nationwide, there was one down and I think it is Gilbert, Arizona, which was very successful. But these programs, what happens is they learned quickly when people dialed 911, they didn’t want the paramedics to care for them in the field and tell them you don’t need care. They expected to go to the hospital.

It is all these perceptions of both physicians and patients that we need to overcome as we advance this discussion about not overutilizing and admitting people to the most appropriate level of care.

[00:13:41] Karen Wolk Feinstein: It’s interesting. We did find in nursing homes that having a nurse available in the nursing home made a dramatic difference. And, you know, we’re working on trying to get more geriatric nurses out there with a specialty in caring for seniors, and just advanced practice nurses in general. So, one of the things that I think has worked, we looked at how many people wound up being hospitalized because of problems with their medication. The problem can go either way. Too much, too little, wrong mix. But we put a pharmacist as an experiment in the ER, and it was dramatic. But when the grant money goes away, so does the pharmacist. I don’t know why; I think having a pharmacist in the ER is really a very good idea. Do you have any perspective on that?

[00:14:43] Josh Luke: Yeah, I know of a very reputable hospital in Southern California that 6 or 7 years ago had a pharmacist and physician that specialized in palliative care come into the emergency department to help avoid hospitalizations. And they were doing very well. Three months in, I got a call from the doctor saying, “Hey, Josh, you won’t believe this, but you know, they, they canceled our program, and it was going so well.” And I said, well, I believe it. You know, I was waiting for you to call me and tell me that because the hospital’s source of revenue is admitting patients to the hospital from the ED.

And for you to be in there, preventing patients from getting admitted that probably did not need to get admitted as you’ve proven, it’s hurting their revenue. And because those calling the shots, the hospital CEOs were more committed to the investors and their board of directors and revenue, that was natural.

As you’ve also pointed out, “pilot,” a lot of people joke, is a word that just means nobody trusted the plan, so we’re just going to pilot it and then put it to bed. A lot of times what happened is if there was a pharmacist put into the emergency department, it was more so for reconciling medications before a patient’s sent home, because as many of you know, a patient, when admitted to a hospital, shows up with six or seven meds they are on at home. The hospital might not carry those meds or have them on their formulary, so they’re prescribed entirely new ones. And then when they go to the nursing home, they don’t have those same meds on their prescription formulary, so they’re prescribed entirely new ones, an average, I think, seven and a half or eight and a half meds per patient.

And now if you can just visualize, you have three different Ziploc bags full of seven or eight medications each and you’re not sure which ones to take. You can understand why a patient would be nervous and have anxiety in that situation. So again, it just gets back to improving communication and just improved processes and shared technology when it comes to the hospital and the nursing home.

[00:16:40] Karen Wolk Feinstein: Yeah, and I mean, not that it is the least bit funny. We’ve also discovered that people go home with that Ziploc bag and then they take the same medication with different names because they already had medications at home. But they don’t understand that they’re actually doubling up. So, I look at medication mishaps, a lot of things you’ve named, by the way, what you just mentioned, we just funded a collaboration between Carnegie Mellon technology experts and the people at Biomedical Informatics at the University of Pittsburgh to work on medication transfers from the hospital to different settings to see if we can’t get better at doing this.

We did a study a number of years ago. Why do people go in and out of hospitals? Who are these people? We talked about medication errors. The one is that a number of the ambulance services do not get paid if they don’t move you to the hospital. We have looked at experiments where the medics cared for people when they could easily in the field. They’re very successful. But, as you know, that can cost the ambulance service revenue. Let’s talk about mental health and the number of people who actually are hospitalized because of mental health conditions that don’t get treated during their hospitalization and right now don’t get treated in the community because of an acute, extreme shortage of resources.

[00:18:14] Josh Luke: Obviously, in the last 5–10 years, we have seen such an explosive growth of that. It has just been, it has been great to see that, you know, these resources have finally come about. I was the CEO of the largest mental health hospital in Orange County, California, for several years, and so I saw firsthand how the mental health crisis is impacting our society.

And then, you know, we saw entire homeless villages pop up in areas where they never had them before. I teach healthcare policy at the University of Southern California. I saw that the mental health crisis was impacting even really affluent, you know, young adults, Millennials that were working in health care for good health systems and just all of a sudden the Millennials and Gen Zs made it okay to embrace and acknowledge the fact that you’re having some struggles with your mental health.

Whereas for Gen X, we, we really weren’t allowed to do that, right? We were told to rub some dirt in it and get back in there. It’s been kind of inspiring and empowering for my generation to look at the Millennials and Gen Z and say, thank you for making it okay to admit that we all struggle with anxiety and at times mental health.

And now we’re putting some resources in place to do that. I am really encouraged by that. I don’t know that we have all the answers quite yet, but whether it’s in person, in a clinic, whether it’s counseling or whether it’s telehealth, I’m really encouraged by the money that’s flowed into mental health support in recent years.

[00:19:44] Karen Wolk Feinstein: And may it increase. It is not enough. I’ve been very impressed at the peer-to-peer counseling success and, believe it or not, the counseling by a robot, the virtual counseling, you know, some things we’ve tried and I was very skeptical, but we are at least doing more to push the frontier and particularly I am amazed at how well people respond to school-based counseling.

Unfortunately, our colleges cannot keep up with the demand, but I think bringing services out to the community, out to where people are, for young people has made a big difference.

We are listening to you, and I know, we know some of these things. We have experimented with them. We know that they work. We know that we could reduce hospitalizations, and we know that hospitalization itself is a comorbidity. What do you think looking into the future? What is going to get our systems to respond? How do we set up a different set of incentives, which is keeping people as well as possible in the community, in the homes in which they want to live, or apartments, should be the top priority? How are we going to get there? What will make the difference so that we stop doing all the things that aren’t really in the best interests of the general population?

[00:21:16] Josh Luke: Well, that’s the million-dollar question. And I think you’ve heard the cliché. If you’ve seen one model, you’ve seen one model because not only is each community different, but each hospital and health system within those communities are doing things their own way as well. And even if you work for hospitals that are in a matrixed organization, the CEOs, they might be five miles apart, but the executives are going to have different ideas and different plans, and they’re going to handle situations differently based on their culture.

It’s a matter of every system is doing it their own way, but they’re figuring it out little by little. The problem ultimately is the incentives in health care are still lined up so insurers can raise rates every year, so their broker can get a higher commission, and the hospitals and health systems have no accountability in how they price their services.

Until that is addressed, we’re going to continue to see individual health plans and payers come up with their own models and little by little, as much as they might work in their own markets, they are not necessarily universal, so it’s going to take time.

[00:22:26] Karen Wolk Feinstein: Some of this seems so obvious to me, to you, to other people who look at this, you know, with their glasses on.

I have a big question though. What about all the initials? All of the healthcare specialty groups, associations in Chicago, in Washington—I’ve been to many of the headquarters—isn’t it time for them to speak up, I mean, on behalf of the public, maybe to say this kind of bloated system with money often in the wrong place and with the wrong incentives? I know a young person here who worked with us, she did great research working with the VA, but they told her that her desire, she was at the top of her class, her desire to be a family practice doc didn’t fit with her level of acumen in medical school and that she should take a year off to make sure that she wasn’t making a big mistake in her life. And we loved her. She was terrific, but I am just asking this question. Where are all the initials—and I think America is uniquely rich in so many associations and specialty societies. Why aren’t they speaking up?

[00:23:51] Josh Luke: It is long overdue, but you mentioned it already—like we’re sitting on each other’s boards. By the time you get to that point in your life and your career, you are usually more financially stable. It is not as difficult for you personally to afford health benefits. It is just going to take some real bravery on behalf of the federal government to just kind of ratchet in what’s become a system beyond control. I don’t know if it can be done at the state level. I think it needs to be done at the federal level. You saw when they tried to limit profitability in the Affordable Care Act of different health conglomerates. That led to companies like Optum that have just become even bigger because they just go buy other companies that seem to have innovative models and keep their profitability down by reinvesting.

It’s taken the problem and made it a different problem that’s even bigger. We just need to keep at it and our elected officials need to recognize that the second largest expense in any business and in a lot of homes is health care. And people need to realize the average American family each year before they’ve seen one doctor or gotten one prescription is paying out of pocket more than $23,000 for health insurance, for the right, for the right to go see the doctor or pick up their first prescription. When you do the math, a lot of people will hear that and go, Oh, I’m lucky. That’s not me. Hold on. Stop and do the math. $600 a paycheck twice a month or 26 times a year. We’re getting up there now, aren’t we? Then you add in your $5,000 deductible and all of a sudden, whoa, those numbers I just threw at you, that might be you.

That is for the privilege of being able to see a doctor once or pick up your first prescription. And if you are one of those people that still says, I’m very fortunate my company provides health care, I think the last 30 seconds of your thought process realizing, Whoa, I’m not that fortunate. The health policy that I have that costs my family more than 23 grand a year just for the right to go see a doctor and pick up a prescription has gotten out of control.

[00:23:51] Karen Wolk Feinstein: Playing off that, which we know to be true, some things are so ridiculous. If you go in for B12 shot, you get a bill for hundreds of dollars. Pretty ridiculous.

What about the disruptors? We have some interesting players who are investing a lot. I mean, Amazon is one. They’re investing a lot in doing something outside of the traditional legacy institutions. What hope do you hold there? Are they going to change our legacy institutions? Or are they going to just fail or be side by side?

[00:26:55] Josh Luke: Yeah, that’s a great question. I’m hopeful. I don’t know if I’m confident. This is Amazon’s third bite at the apple, their third swing of the bat.

I think they have started to deploy some clinics and started to do some hospital partnerships, things like that. So, yeah, I think that’s encouraging. I think we are going to get there slowly. I know Walmart, the clinics at Walmart have put some fear in people in the healthcare industry, to say, Are they going to be able to pull this off?

And I think what we definitely have learned about Amazon, Walmart, and others getting into health care is don’t assume because it works here, it’s going to work there. I think they have realized that and so they’re, they’re slow to open a clinic in a different part of the country and then grow their services from there as opposed to trying to put this blanket across the country and do the same thing.

That’s very important, and I think they are making progress. You know, the one thing they can do that we’ve started to see is direct primary care, where you, if you have, you know, a couple thousand employees that report to the same parking lot every day, whether it’s one company or three companies in that same parking lot, why not put a physician office in there and pay them directly to see your patients? It’s going to improve your efficiency and your productivity at work as well, because people don’t have to leave to go to the doctor every day. With concepts like that, little by little, we’re going to start to get an improved delivery model.

[00:28:26] Karen Wolk Feinstein: Well, let’s talk about technology. I go to a very inspired, I think, eye doctor, eye surgeon, and he has found that there are a lot of things related to your vision testing that are not only mobile now, but they’re also sort of lightweight mobile. You could take them out to where people are instead of having everyone make an appointment and come, for us, either downtown or out to one of our big health centers. centers that you can bring out to where people are. for that?

[00:29:04] Josh Luke: Yeah, but it’s a slow troll. I wrote about that in my book Health-Wealth just talking about direct primary care, gut testing to get your gut tested so you can, you really need to take charge of your own health care is the point. And most of these things we’re talking about, I call it becoming an EHC, an engaged healthcare consumer. And by doing that get your genome sequenced and understand what foods are going to be fuels for your body, what few foods are going to be blockers, pharmacogenetics, understanding which medications your body metabolizes better, going to direct primary care, where you can see a physician. And you know, a lot of people haven’t realized, especially if they’re Gen X or Baby Boomers, or even of the Greatest Generation, there’s really no such thing as a, you know, personal family physician anymore.

The exception to that, and my family has one, is direct primary care, where you just pay the doctor directly, whether you have insurance or not, and he or she gives you access to them 24/7 either via the telephone or telehealth or via text. So, it is all these things that little by little we see creeping into society because those of us in the know that this can be done better.

[00:30:21] Karen Wolk Feinstein: Well, you raise an interesting issue. Tell me how you feel about this. I was on a study tour to the Pacific Rim to some very sophisticated countries. And I was shocked. They said, no, no, we do specialty care, very low cost, no cost, but we charge for primary care because we think people must take responsibility for their health.

You can’t even say that in the U.S. I mean, that would be the least woke thing you could possibly say. But these are, these are highly sophisticated countries who say, we want people to be responsible. I saw that they make it easy in some ways.

You’ve worked in so many different settings. Talk to me a little about what we are going to do about the morale of our healthcare workers? I got to look at the satisfaction surveys in a large system for the doctors and nurses. I knew that people weren’t happy. I didn’t know they were this unhappy. And when you look at 48 percent of physicians who say they wish they had chosen a different career, how are we going to inspire people to love their work? How are we going to get these well trained and I think committed professionals to say, I find my day satisfying.

[00:31:51] Josh Luke: Yeah, you know, again, that’s a complicated answer, but, you know, most caregivers got into caregiving because they wanted to make a difference. They had a personal story. You made a statement earlier that I was going to inject on, so I will now. You referred to nursing homes and you said, I don’t know if people caught it, but you said we got funding to put a nurse in a nursing home and you hit it on the head of the nail. We should actually call nursing home CNA homes, because there’s only two nurses in the whole place and only one of them is a registered nurse. The other one is an LVN (licensed vocational nurse) or an LPN (licensed practical nurse). And both are doing nothing but charting or passing meds the whole time. In fact, one usually passes meds while the other charts and then they reverse roles. The reason there are only two is because that’s the minimum required for an owner to staff to meet the staffing requirements.

So, 95 percent of the care being given in a nursing home is being given by a certified nurse assistant. Their patient ratios can be 15, 16 to one in a nursing home. In a hospital, it is more like 6 to 1, but you find that these CNAs who oftentimes, you know, didn’t go to college or may or may not be high school graduates, but have a caregiver’s heart, are just being run ragged and being disrespected.

I wish I had an answer to that question because it is going to take more than money. The pandemic really brought this to the surface for a lot of reasons, but one of them is because every nurse realized that they could go triple their income to go work somewhere else, even if it were part time or temporary on a contract.

And a lot of them did. They lost that loyalty because they saw financially how they could benefit. They went and worked contract labor, and it started to come back under control. But again, the pandemic really brought the anxiety level up and the contentedness of caregivers to an all-time low.

[00:33:56] Karen Wolk Feinstein: I see the data, but what I do not see is a commensurate response. Am I missing something? I don’t get the sense that this is top of mind at our health systems right now.

[00:34:19] Josh Luke: I just don’t know how much they can do at health systems beyond, you know, good pay rates, celebrating and honoring their caregivers as often as they can. The reality is, you know, hire more staff, and make your ratio lower. But that just gets to the bottom line, so it is difficult to do. So yeah, that’s a tough one, that’s for sure. Everybody is struggling with it across the whole country.

[00:34:47] Karen Wolk Feinstein: Well, I can say this: you see things clearly, and you don’t just dwell on “ain’t it awful.” You have very practical solutions. How are you going to get your voice heard, and where do you want it heard? Where, where could more people listen to these solutions and take action?

[00:35:11] Josh Luke: It’s a great question. I am active on LinkedIn at Dr. Josh Luke and have been for several years. I do a lot of newsjacking or sharing relevant healthcare stories. I just launched my third healthcare podcast. The first two were ranked in the top 10 healthcare podcasts in prior years.

[00:35:28] Karen Wolk Feinstein: I can’t thank you enough. This has been an interesting romp. We have an expression, From your lips to God’s ears. And I don’t know who God is in this respect, but I certainly wouldn’t mind if it hit D.C. and the policymakers. So, thank you so much.

[00:35:49] Josh Luke: Thank you for your time. It has been a pleasure.

[00:35:52] Karen Wolk Feinstein: Up Next for Patient Safety is a production of the National Patient Safety Board Coalition in partnership with the Pittsburgh Regional Health Initiative and the Jewish Healthcare Foundation. It’s hosted by me with enormous production support from Scotland Huber and Lisa George. This episode was edited and engineered by Jonathan Kersting and the Pittsburgh Technology Council. Special thanks also to Lisa Boyd, Carolyn Byrnes, and Robert Ferguson for their ongoing assistance.

Special thanks also to Ariana Longley and Lauren Payne, for helping with the series. Thank you for listening and please take action, whatever you can do to advance patient safety.