Welcome, everyone, and thank you for joining this quality summit session focused on understanding how the COVID pandemic has impacted guideline care. My name is Connie Anderson, and as the CAHP PCI and Chest Pain MI Registry product manager, I'll moderate our discussion today. I'd like to start by introducing our three presenters. Dee Howard has a wealth of experience in nursing and critical care and emergency medicine and joins us today because of her involvement with the Mississippi Healthcare Alliance, where she serves as the executive director. Keisha Medley is the system cardiovascular registry director at Baptist Memorial Healthcare and has oversight of this organization's 22 hospitals in a tri-state area, but is apparently still finding time to work on her MBA. And our last presenter will be Christy McGregor, who is the director of cardiology programs at St. Dominic's Hospital in Jackson, Mississippi. She's responsible for many of their programs, of which a mere handful are their acute MI program, targeted temperature management, and the CAHP Lab. I hope you take the time to become better acquainted with these ladies by reading their bios. Now let's get started. Thank you so much, Connie. It's a pleasure to be here to represent the Mississippi Healthcare Alliance, along with my friends Keisha Medley from Baptist Memorial Healthcare and Christy McGregor from St. Dominic's Hospital. In the beginning of the Mississippi Healthcare Alliance, we were formed with five hospitals that were focused on improving STEMI outcomes. Since that time, now in October 2020, our membership exists with 21 STEMI receiving centers and 65 stroke hospitals. We have grown a lot. The Mississippi Healthcare Alliance's mission is to improve the health status of Mississippians. Our vision is to unite stakeholders to bring about an alignment of efforts that reduce morbidity, mortality, and cost associated with problematic disease processes that plague our community. This graph depicts the Mississippi risk-adjusted mortality rate improvement over the nine-year period that we started the STEMI system of care and data collection. In 2010, you can see Mississippi in the blue bars. We were at 6.8% mortality compared to 5.8 in orange with the nation. In 2019, Mississippi mortality dropped significantly to 4.87 versus the nation to 4.76. We look at mortality as an important indicator of our success with the STEMI system of care. The STEMI system of care began in 2010, and we were adopted as a system of care in 2011 with the State Department of Health. This is a voluntary system of care, and we knew that we had to have a data collection piece that all the STEMI hospitals participated in, so our choice was chest pain, MI registry for PI purposes. All hospitals unblind their data at the State Department of Health when we have PI meetings, and that's all confidential. The same is with stroke. We adopted the Mississippi State Department of Health Stroke System of Care in 2014, and we used the AHA Get With the Guidelines Stroke Registry for those PI purposes. Another initiative that Mississippi Health Care Alliance has been interested in is out of hospital cardiac arrest and ways to improve outcomes for that. Mississippi began participating in the CARES registry in 2018. This is cardiac arrest registry to enhance survival out of Emory University. We have grown that registry now to where we have over 80% of our Mississippi population covered with the CARES registry. We also knew that we needed to have targeted temperature management equipment available in all 21 STEMI receiving hospitals, but at the time, they did not all have that capability, so Mississippi Health Care Alliance used some of our funding to provide equipment for those hospitals that needed the equipment for this class 1A life-saving therapy. And then COVID-19 strikes. We know that COVID-19 affected everyone in the country as well as the world, and really everyone had to rethink how are we going to manage hospital life, how are we going to organize ourselves after this pandemic and moving forward. We knew that a quick response was required in order to work with this pandemic that was associated with COVID-19, so in April 3 of 2020, our governor of Mississippi, Tate Reeves, and his COVID-19 task force asked the Mississippi Health Care Alliance to draft a COVID-19 system of care plan for the State Department of Health, and so we quickly recruited the experts in the field to help plan this both pre-hospital with EMS medical directors and EMS professionals and in-hospital pulmonologists to draft the hospital state plan. We needed to get the word out, so we held webinars for discussion and review of the plan draft among the writers, and then we held a statewide planning meeting with all the stakeholders April 9 so that we could review our system of care plan. The next day, April 10, the state health officer and the Board of Health approved our system of care plan. Mississippi Health Care Alliance is appreciative for the credit that we were given by the State Department of Health for our integral writing of the system of care plan for COVID. Here you can see we got acknowledged on the paper for the COVID-19 system of care plan, and we were very thankful that we could help and participate in that plan. Patient placement was also one of the issues that we worried about for our system of care plan. We knew that in Mississippi, there are very many rural hospitals, and they would have sick COVID-19 patients. We knew that they had needs that needed to be met, such as they needed a stat pulmonary consult, they needed to know where to transfer the patient, if it's up to a higher level of care, or can they stay there at their local hospital. We knew that they were going to need an ICU to put that patient in that they did not have. So where are all these COVID-19 patients going to go, and how are we going to manage them? One of the things that we decided to do was to develop a call schedule with a critical care pulmonologist regionally in our state, and we were able to have them volunteer their own time to answer calls from the rural hospitals and help them to determine whether those patients needed to be managed and transferred elsewhere for a higher level of care. In July, we also had discussions with the same Department of Health folks and the experts to discuss bi-directional patient transfer, because we were suffering from the larger hospital ICUs being full, having no beds, no critical care beds, and possibly having to transfer those patients out of state, so sometimes the larger hospitals were transferring down to a smaller hospital just to find an ICU bed for those patients. Another aspect of COVID-19 has been fear. The public has been told to stay at home. The public has been told to isolate and don't go anywhere, and they took it to heart. They decided that I may be having chest pain or stroke symptoms, but I'm supposed to stay at home, and so that was what happened, and we realized as a nation that we had the same problem going on everywhere. People were not wanting to go to the hospital because they were fearful of catching the virus, and so they oftentimes would stay home and suffer a heart attack or a stroke symptom at home and have irreversible stroke disabilities and then subsequent heart failure from not accessing emergency care. People also have a feeling that they didn't want to bother the already busy emergency departments because whatever I have may not be significant enough, so we knew that people just basically were not seeking emergency care. The Mississippi Healthcare Alliance has had a commercial that we've been sharing with our state for many years now, and it's to educate the public about dialing 911. Don't drive. Dial 911. Let them come to you, and so we took our existing commercial, and we made it COVID-19 worthy by telling people that they really needed not to stay home during COVID-19 if you're having symptoms of heart attack or stroke. We wanted them to dial 911 and come to the emergency department, and we made this effective with this red banner that you can see that goes across the screen for patients. We needed them to seek care quickly, so the Mississippi Healthcare Alliance is continuing to work with the State Department of Health to update the plan of care with COVID-19 as needed, and I'm pleased to say that currently in Mississippi, our COVID-19 cases are trending downward, but we know that everyone must continue this fight until there's an approved vaccine. Now I'm going to turn the talk over to Keisha Medley. Thank you, Dee. From a system perspective, it seemed we had gained such positive momentum until COVID attacked Baptist Memorial. In early March 2020, our system's flagship hospital experienced our first positive case of COVID. While other organizations had the opportunity to transition and adapt, our first case was an employee. This employee worked in a huddled environment, so this resulted in an immediate furlough of 16 staff members. That may not sound like much, but it was the majority of one of the most essential departments in our hospital. This created an immediate staffing challenge. We had to provide for the safety of employees, coverage for the specialty unit, and kickstart the activation of response teams. Supplies were also a concern, and we responded by closely examining our throughput process because this unit, in particular, was centrally located within our facility. Our first exposure to COVID required an immediate action, and in response, we implemented STAT organizational meetings and created definitive action plans. Because COVID first struck our organization internally, some of our facilities went into crisis mode. Our organization consists of 22 hospitals in a tri-state area. With almost 3,600 licensed beds and well over 500,000 annual ED visits, we also had to give great consideration to the impact this would have on our heart transplant and mechanical heart programs. Having such a large system of more than 5,000 physicians and 18,000 team members, it was essential to deliver accurate and concise information very quickly to our hospitals as well as the 61 clinics that would also be impacted. Because of our commitment to quality, it was imperative that we sought guidance from experts and followed best practice measures. For example, we had hardwired processes at our PCI receiving centers, such as bypassing the ED with STEMI patients when activated in the field. However, the challenge became how to remain timely while providing for the safety of staff and patients, but we knew we were not alone. Our relationship with the Mississippi Healthcare Lines began in 2012. We have remained connected via emails, quarterly calls and meetings, and annual conferences. Three of our facilities are located in the north region and one is in the central region. Over the past eight years, we have truly developed a fluid relationship with open communication and mutual support. This was clearly evidenced by their immediate action and STEMI process of care revisions distributed as Dean described. Our COVID support network was made of trusted sources that we could depend on. COVID was impacting our colleagues across the country, so networking and sharing information was essential to keep us informed. The Mississippi Healthcare Alliance's updated STEMI process of care was provided right away. We also reached out to our contacts in other regions, including New York, Oregon, Dallas and across Tennessee. A very trusted source for guidance was the American College of Cardiology and MedAxiom webinars. We listened to the experiences of those in harder hit areas, such as Seattle, New York and China, among others. It was actually the most optimal time to take advantage of the solid relationships we had built with our EMS providers. We recognized they would be critical during this time and their commitment for open communication was essential. In 2017, our system implemented an EICU center. We were already providing monitoring for more than 300 ICU beds across our system, which allowed for the extra support to those patients and nurses, especially related to the increase in isolation rooms. As these maps showed, pulmonology services were arranged to provide additional coverage to most of the state. Our organization met the needs of the Northwest and the North Central regions of Mississippi by granting privileges to our pulmonologists for all facilities to ensure coverage was available via teleconsult. Our rapid cycle COVID response also required adjustments to staffing. This meant activating nurses, including cardiac nurses from our CV registry department and other personnel that were working in non-traditional roles to be readily available for service. The activation of the central command center was one of the most critical components to our success. Our senior leadership immediately created the round-the-clock source for all facility leaders to discuss patient volumes, staffing needs, distribute supplies, and other immediate issues. In addition to how care was being delivered and by whom, we also had to seek guidance from our non-clinical teams to ensure where care was being delivered was safe. Our facility services team inspected and installed HEPA filters and increased the number of our negative pressure rooms. They also mounted devices in patient rooms to allow for our expansion of tele-services. Our procurement teams' fast response secured the isolation and protective equipment that we would need for our system. And our dedicated environmental services teams were immediately called into action and provided additional support for isolation and high-touch area cleaning. Our COVID coping strategies included social media messages. We've posted over 800 stories to Twitter, Facebook, and Instagram, in addition to billboards, bus wraps, and public service announcements, much like these shows. Centrally accessible resources, including our SharePoint and central command center, provided current bed, ventilator staff, and support availability at all times. Our COVID resource call center. We created this and staffed it with RNs. This is a 24-hour call center that's processed more than 35,000 patient calls just across our region, providing details for testing locations, general questions about symptoms, and providing negative results. Call volumes have been as high as 400 a day, and we have performed more than 250,000 COVID tests. Tablets and iPads were made available to our patients. Decreasing anxiety and allowing communication during visitation restrictions was important. We were seeing cases with poor outcomes because the public was afraid to seek care, much like what these described. They did not want to be isolated from their loved ones, and they were afraid of catching COVID while in the hospital. So having those iPads allowed them to talk and to see their family, and the family had peace of mind as well. Our emergency department leaders worked with EMS to understand the process changes related to safety, infection control, and minimize their offloading delays, and utilizing technology to clearly communicate information from the field. We have treated over 4,500 COVID patients so far. So in summary, Baptist recognizes the value of partners, refinement of processes, and continual practice during this pandemic. We relied upon collegial communication to develop standardized processes for care, quickly adopted and distributed those processes for safe care delivery while actively monitoring for surge and lulls in cases. We enhanced communication and access to care via teleservices, EICU, and the COVID Resource Call Center, and we maintained an empathetic approach to care while continuously evaluating opportunities for improvement. I would like to turn it over to Christy now as she shares her hospital's experience. Thanks, Keisha. I am Christy McGregor. I'm the director of cardiovascular programs at St. Dominic's. We are a 535-bed acute center and a large STEMI-receiving center, especially located in the center of the state. We get a lot of transfers, and we're very busy with cardiovascular care. So our cath lab is seven cath labs, and then we have five that are committed to coronary, peripheral, vascular, as well as venous studies, and then we have two for EP, and we have a hybrid where most of our structural heart resides. When COVID first came, I don't know if y'all have seen Inside Out, but this is exactly how I felt. I started with sadness, and then on a really good day, I could go through all of these about 10 times. As leaders, we have to go ahead, get finished with being overwhelmed, and then break it down in many steps. We felt like this was the four main areas we really needed to concentrate on, education, communication, implementation of new processes from these guidelines, and then we knew there's going to be a lot of operational changes to accommodate the new COVID-19 world. So let's start with education. I felt like we really needed to know about safety as well as what to expect of CV providers. Of course we had a look at CDC recommendations, what we felt from that and the sky paper that ACC put out as well on how to do a cath lab is we wanted to designate one cath lab that was for COVID positive or persons under investigation. And we stocked that room very well with PCI supply so that would limit the traffic. It was a lab that was away from the rest of the other labs so there would not be a lot of cross contaminations by any means. And we wanted to make sure that it was big enough because STEMI certainly can become intubated procedures where we were safe and we are away from any type of aerosolized procedures. We also had to make sure we had specific PPE and enough of the PPE. We had to make sure that we recognized when a COVID-19 patient was coming. So we had to work a lot with IT to make sure that was on our orders before we took the patient back so we could put them in the correct lab. Cleaning recommendations, that was a new one for everyone. And then team member support. We wanted to make sure as this time was very scary and nobody knew what was going on that they had the resources they needed to take care of themselves because a healthy team gives you great outcomes with your patients. And then we needed to know what to expect as CV care providers. How are the STEMIs going to present? There was a lot of myocarditis at the beginning and there still is even six weeks past your COVID intubation. And then we also needed to know about cardiogenic shock. We knew people were going to take a long time before they came in and we're just going to drag their feet. So we did some virtual education on Impella because that's our support device that we use. And we wanted to make sure everybody was on the top of their game for that. You were going to see an increase in outside hospital cardiac arrest. Post-mortem care, we did not know exactly what was going to go on with that because we've never taken care of this before. And then the ACLS recommendations. Just practically all this information was a lot, right? So we ended up having a COVID binder and we wanted to make sure that it was in print because we also were being flexed. So I had half my team one day, half team like two days later. So we had to make sure that that communication was done very well and purposefully. And I'm sure everybody kind of felt like this, as soon as something was learned, then they changed the rules. And so you never knew what was the parachute that day. There was so much information out there. So we had to make sure that we use trusted resources. And these are just some of the places that I went. I really was married to the ACC COVID hub. It was a lifeline. This is where we got a lot of our information that we put in our COVID binder. Also the Mississippi Health Care Alliance, when they did their COVID-19 STEMI plan, we printed that out so everybody would know what is the expectation of the state and what was our part in that as well. Of course, the CDC was a great place to get a lot of our information as well. I will have to give a plug for registries here. We are not new to having new process improvements, plans, and that has a lot to do with the fact that we participate in a lot of registries. And the registry is a great lens to see which priority project needs to take place in your institution. So the fact that we already had that foundation and we already knew how to look at national benchmarks and get everybody on board for a vision, I think that really helped us be successful in drawing this up quickly. Communication was huge. You know, you can have a ton of useful information, but if you don't share, then your team is so frustrated. And it does not build any trust, right? So what we did is make sure these are just a few of the people that we had to communicate with. But these were our main people that day in, day out, daily huddles, we were talking with. And the Health Care Alliance was a huge part of that. They, before the Department of Health even sent out their bulletins, they kind of were my lifeline before I was able to have constant communication with Department of Health. Plus the fact of the relationships that I had from this organization. STEMI coordinators, we get together a lot. Thanks, Dee, for making us do that. Have a lot of good relationships with EMS as well. And so being able to call up somebody from the North and somebody from the South, how are you doing this? How are you doing with your cath lab for COVID pre-testing, things like that. It was essential for us to not feel alone in this. These are just some of the implementation guidelines that we had to do. As you can see, it was a lot, especially at the beginning, it was a ton of new things. What I want to kind of concentrate on is how we did a little bit different with our non-STEMI and STEMI pathways to the cath lab. Like Keisha said, we also do ED bypass, but because we kind of got burned in the first few weeks of COVID outbreak, we decided to do a thoughtful pause in the emergency room, do a mini screening, and then send them up. That was a huge change for us and especially for our EMS providers. So we had to do a lot of education on that. Practically what we did for the ping-pong match for us was all this different information that the physicians found, what we found as a team, and they would take one piece of the cath lab that they wanted to pay attention to and they divided it up between their partners and then they would give me a little bit of that information. And what we came out with several flow charts and several guidelines. What we did for this STEMI pathway was laminate it and then we also put them in every lab so there would be no confusion. We put it down in the emergency room and this was after we got buy-in from everybody there. And then we also put it on the big whiteboard so everybody knew the expectations for that as well. So we also had to change our non-STEMI pathway, maybe more of a thoughtful pause on some of these, especially if they were COVID positive. And so we did have to change a little bit of our working around with that, especially on the inpatient side. I wanted to give you a snapshot of what we saw from 2019 from March to June, which is the green, compared to March to June of 2020. And I wanted to see where we fall on the trends internationally. So you can see our total activations really didn't change. We had the same amount in activations as well as STEMIs. What was very surprising to me is that we had less of the late presentation than we did in 2019. But if you look over to our cardiac arrest, we had more of those. So not only did we have late, but we had way too late. Just like Dee and Keisha have said that we've seen, people were too scared to come. And I think it's going to be very disheartening when we see how many non-COVID victims there were because of CD deaths and people staying at home just because they were way too scared to come in. Our door to balloon time, like I said, we were a little concerned about that, but we still were able to provide quality care for these patients, even with that thoughtful pause in the emergency room. Some key takeaways here, this is so cheesy, but flexibility is absolutely the best ability. Communicate, communicate, be purposeful, get that trust with your team. Abstractors, you have a huge job to let everybody know what's going on in the COVID world and how can you make that translate into any processes that need to be changed. Encourage your entire team. Even if you're not directly with patient care, we all need to know that we have this incredible responsibility to leave a positive impact on a patient's timeline. And that should never be taken for granted or just thought of as ordinary. So relay that to your team. And also use resources. CardioSmart is great for patient education, especially during this, everybody, I'm so scared to come to the hospital. But also the ACC COVID hub was essential in the middle of all of this. And we just want to say thank you. Thank you, Dee and Keisha, what I love about working with the Healthcare Alliance and these ladies. PCI centers are kind of seen as competitors sometimes, but we really want to make a difference in our state and make the citizens' health of Mississippi much better. Thank you, ladies. You each painted a detailed picture of the rapid responses demonstrated in the face of COVID. And Christy, thank you for the registry plug. That was unsolicited, but I appreciate it. So my first question is for you, Dee. You mentioned the Mississippi Healthcare Alliance recommendations for COVID were released to the state health department and shared with Mississippi hospitals within states. That's a phenomenal turnaround time. Can you share with all of us how you were successful in coordinating that effort? Sure. So we have been forming relationships across the state with the Mississippi Healthcare Alliance since inception. And we were already organized and able to get with our contacts in the pre-hospital world and our nurses and doctors across the state and get to work immediately on developing that plan. And the governor's task force ask for the Mississippi Healthcare Alliance was a huge plug for us. We felt very needed in a time that we could actually answer the call and we did. Yes, you definitely did. It's very impressive. So Keisha, your organization had a baptism by fire when COVID hit your healthcare system internally. Can you share how long it took your organization to pull together a crisis center? Yes, actually, our large organization requires constant communication to run smoothly. Within about 48 hours of learning that we had our first case, we had activated our fully functional command center. We used a recent national experience to have already sharpened up our responses, making sure that our team manuals were updated and that our communication lines were straight. That happened even before COVID. So for that we were in an ever ready state for that. Also, because of that, and we were able to take such actions and really bring that together, we were able to close our command center within just a very few months because we had hardwired so many of those major processes, and then just began to treat COVID as routine. We knew it wasn't going away for a very long time. That's a good analogy there to be able to handle it as routine, right? That's what a well oiled machine can do is handle the extreme as routine. That's great. So in those early days of COVID, how did you ensure information was getting to your whole system? You have a very large system with hospitals and clinics and obviously, how to handle COVID patients, how the staff should protect themselves, all of that's very critical. So how did you ensure all of the right information reached all the right people? And actually, thank you. That's a very, very good question. Well, our leaders value transparency. We established a daily call with our leaders who then disseminated the information through our established communication chains per department. And additionally, our our corporation's president implemented a weekly video series where he provided key information to the entire organization related to our COVID challenges and responses. Wow, that's, that's awesome. Because we certainly learn information better hearing it and seeing it right, not just getting it on a piece of paper. That's really impressive. Alright, so my next question for still for you, Keisha is, you mentioned that, of course, you had to immediately adjust your staffing. So staffing has been a real challenge for healthcare systems during COVID for a multitude of reasons. Without going into all the detail, can you just share with us your or the organization's philosophy for staffing right now? Yes, and staffing was a great, great concern. Since the very beginning, our senior leadership really took full heart to that. And while we did not have to furlough our staff, we were able to provide some flexible staffing options. We did have people now cross training into other areas that maybe they hadn't worked in before. But it was all in the servant's heart. It's all in the servitude of making sure that we could all remain strong together. Yeah, thank you. That's good to know and exemplary as well. So Christy, I have a question for you as well. You demonstrated your flow charts, which were fabulous. And but again, you also mentioned that several team members and cardiologists were involved. And as we all know, that's it's hard to to circle all the opinions and all the information and be able to condense it into a flow chart. So how were you able to do that? Well, something about the words pandemic and death toll makes everybody jump on board all of a sudden. I was so proud of how everybody just stepped up and there wasn't a lot of differing opinions or in fighting anything like that. I think getting the people who actually do the work is a key to adoption of the to adoption of the implementation process. There is like with that flow chart, the cath lab was I had another lab in mind and the cath lab was like we really would like to have it for two because we can chart outside the room. And that's one of the few labs that we can do it. So after getting it from the the cardiologist, and then hearing the staff's information and taking that then tweaking it, giving it back. Another thing was, I made them do all the printing and the lamination. So that wouldn't just be me knowing it, it would be key leaders. I had x-ray techs doing it and I had nurses doing it as well. So that was really good in conveying the message and really pulse era is our activation system. So every time we had a STEMI activation, we were able to put remember to stop in in the emergency room for a quick COVID screening. And that was extremely instrumental in getting it done so quickly. No, and I was going to ask you how you got by and but I think you said that the pandemic and the high death toll was the motivator, right? It didn't really take a lot of arm to us. That was unique to this situation. So I'd like to ask you because you're more hands on with patient care right now. You're, you're, you often miss some of our practice calls because you had to manage patient care. So can you share with us some of the most challenging aspects of managing patient care and dealing with COVID and or at least having to be mindful of it? I would say, probably creating a non COVID care zone has been more challenging to me than doing the COVID piece because that's a little bit more contained. Well, when you have surgery, you have echo, you have non invasive, all these different testing plus you plus a pre op area, it is very hard to make sure that everybody's streamlined. So we just got in a, our big conference room, I did the sticky note thing aside, we assigned different things, different projects to people down to when they registered. I mean, that's a huge piece of how we get things done is registry. So just making sure that everybody was talking the same language had the same goal. And we had an entrance plan, a procedure plan, and then an exit plan for those patients. So I would say really the most challenging is making sure everybody understood the goals for the non COVID care and that we were meeting every expectation that the CDC had lined out in their documents. So we just took the document, and we put in action and make sure that it, you know, matched up with what they were saying at the CDC. Yeah, wonderful. Thank you for that. So my last question is for you, Dee. I know the Mississippi Healthcare Alliance is obviously a wonderful resource to the hospitals in Mississippi and to the State Department. But I would expect that that's a two way street. Can you share with us what sort of relationship you have with the hospitals and how they influence what you're doing and how the Mississippi Healthcare is organizing and communicating with hospitals? Like how do they, you know, influence the Mississippi Healthcare Alliance? Yes, well, it definitely is a two way street. We work closely together with all the STEMI coordinators at each hospital. And every other month, we have a webinar meeting where I used to travel to the hospitals. And I would go to each region, making sure that I visited face to face with folks. Now we've just been doing WebExes, but hopefully we can get back to face to face. Knowing people and getting to know folks, you know, around the state and what the Alliance does to, you know, offer our assistance should they need it is huge. And so interpersonal relationships are important. So I'm glad that we've had that because now that we've gone to webinars, you know, I still know who those people are. But you know, sharing questions and answers, we started a listserv for STEMI coordinators, because you know, staffing can change and you may have a new STEMI coordinator that's kind of not sure what their role is. So I would defer them to the regional coordinator and we have three regional coordinators that are the experts in the field that are sort of like a big brother, big sister type thing that they can go to to ask for direction. And just the fact that Mississippi Healthcare Alliance volunteers are a phenomenal group of people and they're dedicated to our mission and our vision. As Christy said, you know, when we come to meetings, we put the swords down and we talk about what's best for our state. And so we're in a non-compete mode at that point. And of course, getting together quarterly statewide. We do that with a social event at the beginning and then we meet in person. That may change, but we do that quarterly so that people can get to know each other and actually, you know, develop relationships, which is a good thing. Right. Well, we'll stop now because we could talk forever. You just said that the folks involved are phenomenal. And I would have to agree. The three of us, the four of us have been working together now for months. I've learned so much. Thank you all for your dedication, your professionalism, your leadership. I appreciate it so much. So if anyone has questions about this presentation, feel free to email ncdr.org and thank you for joining us. Thank you.

discussion

presenters

healthcare organizations

COVID-19 pandemic

response

challenges

communication

collaboration