All right, welcome everyone. We are so delighted that you have chosen to spend your time with us today during this quality summit. So thank you for joining this hot topic session. It's going to be focused on the value of chest pain center accreditation and creating a culture of process improvement. Now my name is Carrie Morris and as the chest pain center accreditation clinical product manager, I will be moderating our discussion today, beginning with introducing our presenter. So who, who is joining us today to present is Ms. Susan McGowan, and she is a fantastic chest pain center coordinator out of Texas at Texoma Medical Center in Denison, Texas. And she has a wealth of knowledge and a great passion for ensuring quality patient care that's delivered and success, and she's successfully led her hospital through accreditation. So I hope you take a moment to read her bio and get to know her a little better. Now for all of you guys that if you would take a moment, whether you're on your app on your phone or on a computer to find the discussion and the questions tab. So I'll be monitoring that during the presentation and so you guys can put in your questions or any comments that you would like to contribute to the discussion as well. And so look through there for your answers. Now I'd like to take this time to thank Susan so much for her willingness to participate and to contribute to our learning and sharing of their experience of going through the accreditation and really building the process improvement culture at her hospital. So let's get started. So Susan, I will turn it over to you. Thank you. Good morning, everybody. I'm Susan McGowan. I am the chest pain program coordinator at Texoma Medical Center, and I've been asked today to come and talk to you all about the value of the chest pain center accreditation and creating a culture of process improvement. As for disclosures, I have nothing disclosed and I have no conflicts of interest. So a little background about Texoma Medical Center and who we are. We're located in Denison, Texas, which is approximately an hour north of the Dallas-Fort Worth metroplex and just south of the Texas-Oklahoma border. Over the years, we've grown from a community-based hospital into a healthcare provider with more than 414 licensed beds, with many more on the way. Our primary service area spans more than 40 miles, encompassing both Grayson and Fannin counties in Texas and Marshall and Bryan counties in Oklahoma. We're the largest provider of healthcare in the Texoma region. So at TMC, we've dedicated ourselves to creating a regional center for cardiovascular excellence. With a full complement of cardiologists and cardiovascular surgeons on the medical team, we're ready to take care of the hearts that matter most, which are the ones of our patients. At TMC, we have the first cardiovascular program in the region that has been treating hearts since 1982. In addition, we're the only hospital in the region to offer open heart and coronary artery bypass surgery. We provide patients with an individualized approach to heart care and multidisciplinary and experienced team members, including physicians, nurses, techs, and outpatient services, such as cardiac rehab. The mission of TMC's chest pain program mirrors the mission of our organization as a whole. Service excellence, continuous improvement, and patient-centeredness are at the heart of our mission and the basis for our guiding principles. One of the most essential ways that we choose to do this is through our process improvements. At TMC, we as a facility have a process improvement plan. Its intention is to provide a framework of guiding principles for all of our staff members in the facility. It also sets the expectation and encourages our staff to participate proactively in the improvement process. At TMC, our mission is to provide excellence in clinical care to our community, that our patients will recommend us to their families and friends, physicians will prefer us for their patients, purchasers will select us for their clients, employees are proud of, and that investors seek out for long-term results. Some of the guiding principles of the PII plan that we have here at TMC is to provide quality, safe clinical services and demonstrate superior patient outcomes, to provide a culture where care is delivered in a safe and timely manner and care dimensions are measured, monitored, and continuously improved upon, to identify and focus on functions that are important to our customers, to implement changes which will increase our customer satisfaction. So at TMC, our model for continuous improvement, in order to do this, at first you need to have an aim statement. It's what are you trying to accomplish? You have to have different measures where you can use to gauge on whether or not you see the change as an improvement or not, and then also an improvement trial. So what changes can we make that will predict or lead to an improvement? The primary method of continuous quality improvement used at TMC is the plan-do-check-study model or the PDCA, and we integrate it into the workflow of each department and each director here at the hospital. So for those unfamiliar with the PDCA, the plan section is where you recognize an opportunity and then you plan a change. The do section is where you test the change by carrying out a small-scale study. The check or study portion is where you review the test, analyze all the results and data, and identify what you've learned. The act section is where you take action based on what you've learned in the check step. If there's anything that needs to be improved or tweaked upon this process, you'll go back to the planning phase and then go through the process again. It's a cyclical process that you go through until you reach your intended results. So one of the most important parts of doing a PDCA or causing any type of process improvement is to build a team that's appropriate. So you want to assemble a team that's knowledgeable about the process and diverse in their thinking styles. The team should be compromised of experts, but remember to include representation from any relevant upstream and downstream suppliers and customers. You want to have a team leader. The team leader should be familiar with the process and experienced in managing processes and meetings. You also want to start with a smaller team size and keep it at a manageable number. Once you get more figured out and you have more of a plan moving forward, you can extend your team to other departments and other areas of the hospital as well. You want to make sure that you have a meeting time that'll work with everybody on the team so that everybody can intend and share their ideas. You also want to assign roles and make sure that the team members are clear on what their job is and what goals and expectations they have. And what goals and expectations need to be achieved by them. And then most importantly, you want to write everything down and take good meeting minutes at all of these meetings so that you don't miss anything. By not writing things down, sometimes you miss some good ideas that you want to go back to later on and try. So next, we went through incorporating this PI culture into our chest pain program. Our guidance statement for the Version 6 Chest Pain Center with PCI Accreditation has the measure that a quality improvement plan that addresses annual measurable goals, metrics used in goal setting, explanation of process improvement initiatives, and a method of process improvement evaluation and resolution. When we were trying to come up with a plan for what we could do for our accreditation, we were looking at the different things through the tool and looking at the different reports to see where we were really lacking on compared to other facilities and compared to what the benchmarks are. Once we started doing this, we became apparent that we had a lot of improvement that we could do with our cardiac rehab process. For those unfamiliar, cardiac rehab is a secondary risk reduction program that's designed to improve cardiovascular health following cardiac related events or procedures through prevention and management. There's strong evidence to support that many cardiac rehab programs can significantly reduce the risk of death from any cause, but also decrease hospital readmissions. Despite its many benefits historically, enrollment nationwide and participation in cardiac rehab programs remain low. Here at TMC, looking at our March 2019 data, we saw that only 30.56% of eligible PCI patients were receiving evaluations or referrals for cardiac rehab at discharge. When we found this, it was clear that there was more that we could be doing to improve the overall health and quality of life for our cardiac patients. We needed to put more focus on our outpatient services and all of their benefits. In order to do this, we sought out to develop our aim, our goals. Our goals here were to increase referral rates of eligible patients by reducing system and patient barriers to participation, while also improving awareness about the value of cardiac rehab. This became our plan for our PDCA moving forward. Next is to structure and process. This is just talking again about what we were going to do. We started to collect data and we started to analyze it to try and find where our weaknesses were. We then shared and reviewed our data with other team members and looked for opportunities. We had our physician champion, our quality improvement team, and we worked together to develop a performance enhancement collaboration. Then we had our medical director champion, my chest pain quality coordinator, and our CV director partner together to see what else we could do. Our physician champion and quality coordinator and CV director began sharing these with their departments and their underlying peers to help facilitate the process. What we did, and this is more basic in what we did, what we first did is we assembled our task force. We looked for people that needed to be involved from the ground floor on this. We got people from IT, our cardiovascular services department, members of quality, members from our cardiac rehab, and then the chest pain coordinator. We met and originally we just discussed the current state of our cardiac rehab referral process and any areas that we all felt that might be hindering from getting as many referrals as we were wanting. We also brainstormed different ways that we could increase compliance with these. We then discussed physician related issues regarding the electronic cardiac rehab orders as well as problems they were having at cardiac rehab with actually receiving these referrals. We started out small by incorporating cardiac rehab evaluations and referrals by incorporating them into our post procedure order sets for PCI patients. We had this changed onto all of our interventional cardiologists order sets as well as their mid levels who sometimes put on these order sets for them. We then created a shared Excel spreadsheet that was used between the cardiac rehab staff, cardiovascular services staff, and myself. On this spreadsheet we had all PCI patients and we tracked which patients were eligible candidates and who actually received the evaluations and referrals at discharge. Initially we used to track it and gather baseline data. We could sort it by provider, find out who our problem providers were, who wasn't being ordered or see if we can identify any trends when we were missing these. And then we used it to follow up. Our cardiac rehab nurses then would find any patients that maybe missed a referral or missed one of these evaluations at discharge, contacted the cardiologist to find out if there was a contraindication as to why this patient didn't receive it and if it was simply just missed, we then got an order placed at that time by the physician and then were able to reach out to these patients to get them enrolled in cardiac rehab. We also started to include cardiac rehab referrals in our physician performance measures and began sharing this data at our chest pain committee meetings as well as our cardiovascular services meeting, which is attended by all of our physicians. We compared their data and showed them the improvement and really talked about different things that we needed from them moving forward in the project. So here you can see our metrics. This will show you the percentage of eligible PCI patients who received cardiac rehab referrals. In March that's where we started our study and collected our baseline data. We were at only 30.56% of patients who had had PCI that were eligible that were actually getting referrals. You can see in April when we started bringing this to the forefront, we started educating our nurses and our staff, our physicians and their mid-levels about why it was needed and who it's appropriate for. You can see where our numbers started to increase and then all the way to September we hit our goal of 75%. We went to 75.5% of these patients receiving cardiac rehab referrals at discharge. This was an increase of 44.94%. This next slide shows our cardiac rehab metrics. These are our overall TMC cardiac rehab patient volume. So when we did this process, not all of the patients, since we're a regional hospital, it wasn't appropriate for all of our patients to come to TMC's cardiac rehab. We do service 40 miles. We have a lot of patients coming to us from out of town, some out of state, so we had to find ways for them to be able to go to cardiac rehab even if it wasn't our own cardiac rehab. So we did recommend that they go to places closer to them if it would make it more likely for them to go and we worked with them to help get them established with other providers in our area. This slide just shows our overall volume and how it increased from March at 246 patients and then all the way to October we saw our highest number of 412 patients at our cardiac rehab here at TMC. Which had an increase of 67.48%. So the current state of our cardiac rehab. We were able to increase our cardiac rehab referrals among our interventional cardiologists and we also increased the volume of patients at our cardiac rehab. So much so that we were currently at max capacity and hired some new full-time staff members to cardiac rehab due to the volume increases. We also increased referrals to outside cardiac rehab centers because, like I said, this was always about what was best for our patients and their needs and not what was just going to benefit us as a facility. Our hopes are to continue this process and expand it to our other eligible patient populations such as our CHF patients and our open heart patients so that we can continue to improve this program and improve the health of our patients here at TMC. I would like to give a special thanks to all those involved. Dr. Scott Turner, who is my medical director, Kim Pfeiffer, who is with the ACC, who was my accreditation specialist and tons of help, Carrie Morris, who has been so kind and supportive throughout this whole process, Lisa Smith, the director of cardiovascular services here at TMC, the TMC quality department, and all the amazing physicians, staff, and volunteers at Texoma Medical Center. If you have any questions or would like any more information, you can submit your questions to accreditationinfo at acc.org. Thank you very much and have a great day. Wow, Susan, that was an amazing presentation. So thank you so much for sharing the great strides that you guys made at your hospital while going through the accreditation. So I bet your CFO was extremely excited about the growth in your program. Yeah, so it was funny. So when we presented this at our version 6 site visit during our presentation afterwards, the CFO pulled me aside and he wanted to know more about the numbers and just how much we had increased. And then he went back and quickly pulled out his numbers just to see how much financially we improved from this, which it was a lot, enough so to get the new staff members and enough so to reach max capacity. Then it's also awesome that we got to share it with other facilities in our area that aren't incorporated with us, but still can offer the same services. That is amazing. That is what accreditation is all about. So we are so proud of you guys. So can you share with us maybe an unexpected challenge that you guys might have faced when you were going through this PI project? Yeah, so we were able to get it built into our physicians order sets and we thought that was going to solve the majority of our problems. If we just have it in their post order sets, then surely it'll get ordered at discharge. Well, in our Cerner system that we use, there was some type of glitch when we moved our cardiac rehab slightly off site. When those orders were ordered, they weren't making it to the task list for nurses at cardiac rehab. So they weren't seeing the prescriptions. So they were thinking that we had just slowed down. There was some IT issues that were happening that we had to get to the bottom of to make sure that when the prescriber was ordering it, that it was also notifying our cardiac rehab staff that they had been ordered as well. So that was the first thing that we, the hurdle that we had to jump over. And then it was just really a lot of education, both to our providers, our hospitalists, the nursing staff, and making sure everybody knew exactly what this meant and then how to provide this education to our patients so they understood the benefits of cardiac rehab and what all it can do for you. That is wonderful. Okay, so one last question that I have is, how did you guys go about establishing that relationship with those outside vendors, those outside cardiac rehab centers to get your patients plugged in? Well, being the regional center that we are, we do offer some services that some of the other smaller facilities in our area don't offer. For that reason, we already have a great relationship with a lot of our surrounding hospitals because we do work with them. We work with them even if they're not accredited. We kind of help them teach them the ways, teach them best practices and what we would like to receive patients from them and help them meet these goals. So we've already worked with them a lot on different cardiac policies and procedures and different things we like to see. So being able to provide these patients with something closer to home that they might actually attend to, as soon as we present it to them as an option, they were more than willing to make room for our patients or give us any needs and resources that we would need. And just making sure to always follow up with them and work with your local places. We're all in the same goal. We all have the same goal in place. We all are looking out for our patients. And so really, it's not as hard as when we think to work with other facilities. Even if you're not under the same umbrella, everybody still wants the same thing. So it really hasn't been that difficult. That is fantastic. Well, again, thank you so much to Susan and to her wonderful facility of sharing their journey through accreditation and their great process improvement that they've been making and for their passion to create methods to care for those patients that do need cardiac rehab. And so thank you so much. So on that note, so we will come to a close for the day. So again, if you have any questions about this presentation or about what accreditation services could do for you, please do feel free to reach out to us at accreditationinfo at acc.org. And I'd like to thank you for your time today, sharing that with us today. And with this, we will close. Thank you. Thank you all. Thank you, Carrie. Thanks. Okay, so let's continue on with our Q&A here for just a couple more minutes. So let's hover over the creating that culture of process improvement just a little bit more. So shortly after your accreditation site visit, Susan, your accreditation review specialist, Kim Pfeiffer, reached out to express how incredibly impressed she was with the true engagement from every department. And that's something that we don't always see. And so it truly is a shining light for hospitals to be able to do that. And we are so excited to highlight your facility for others to follow. So just out of curiosity, so do all of your hospital employees get quality or process improvement training, or is it just specific staff members and then that information is trickled down? So what does that look like at your hospital? So at TMC, we've always had a big focus on PI and wanting to constantly improve ourselves. This really geared up a few years ago when we got our new CNO, Anne-Marie Schenck came to us and she's just been wonderful. And she definitely has a heart for PI. So when Anne came, we went from just having a little bit of introduction to our new employees the PI process and how to do a PDCA and just how to just improve things around us. It really just amped up more. Now, besides the training they get upon initial hospital orientation, when they go back to their home floors, each director and manager of each floor has to work with their staff to create four PI projects a year, either specific to their needs on their floor or the hospital as a whole. Give me anything from CHG baths for people with Foley catheters to things like improving our door to EKG times. That's really like a great PI that we did here. We were looking at our door to EKG times when we're going through our accreditation reports with Kim on the phone, our wonderful specialist who met with us, and we saw that we had a lot of room for improvement. We weren't really where we wanted to be. We were hovering around 12 minutes and which was not inside our goal of 10. So we looked at some of the errors that we were having and some of the things that were leading to these delays. We started working with our physicians and decided that what we were going to do when we had a chest pain patient come in or anybody with those atypical symptoms was those patients go straight back like always, but now any available staff in the ER, be it our techs, our phlebotomists, anybody, kind of swarm that room. They go in and everybody has a job. While one person's quick registering the patient, another one's getting an IV started while another one's doing the EKG. If the physician isn't able to be in the room at that very moment, there's someone on stand, another staff member set to deliver that EKG directly to the provider, discuss the brief history and the symptoms, and then the provider will read it right on the spot and say whether or not there's anything emergent or critical that needs to be addressed right then. It's then taken back to the patient and the provider follows along with them and that's one of the ways we were able to chop those times down just by having a real pit crew approach in our ER. It's decreased our times. We now average about three minutes for EKG interpretation by our physicians. Three minutes, that is so impressive. So I love what you said, the pit crew focus of the team approach, because so often we think about processes in sequential order rather than simultaneously and so I love the word picture of the pit crew of everybody focused on doing a role but it's all done in tandem with the other and so it's that's a great process and so that's something that certainly other hospitals can benefit from. So we know that your team had outstanding outcomes from your cardiac rehab patient population and then now hearing about your EKG, I do remember hearing of other areas of improvement. So I think I remember from one of our previous discussions or maybe it was from Kim, had mentioned the work that you guys did in the emergency department along with your laboratory staff related to troponins and capturing that stat troponin and the urgency of getting that ran and resulted. And so can you elaborate on what that process looked like? Absolutely. So the thing with PI is as soon as you improve some of your less favorable data, some of your other data starts to look not as hot in comparison. So when we really tightened up our EKG interpretation times, it made our initial troponin turnaround times not look as hot as they once looked. So we decided we needed to do something to improve this. So we started working together with the ER directors, the laboratory directors and staff. We had everybody kind of sit down and we would follow the nurses and we kind of follow the process to see about how long everything was taking us. So we'd look and see how long did it take our physicians to put the chest pain order sets on, how long it took our nurses after that to draw the labs and get the labs sent to the actual laboratory, and then how long it took our lab once they had the blood specimen to do to actually get our results for us. When we were doing this we collected a lot of data, probably more than anybody would ever want to, but it on average our our lab was taking consistently about 30 minutes to get us our results. We knew that wasn't going to be a time that we were going to be able to affect that much, so we had to work on everything before the blood got to the lab to try and improve that to improve our process. One of the things we did was we provided all of our ER staff, the nurses, the techs, everybody with these little red sharpie markers that can attach to their badge so they have them with them at all times. Whenever a patient came in that had a stat troponin order, these nurses or staff would take that red marker and put a line on the label of the green top to send to the lab. It was just a visual reminder for our nurses, our techs and our phlebotomists to know that this was a stat troponin, it is a top priority. When those green tubes with the red lines make it to the lab, those are pulled out first and those are ran as a priority over all the other labs. And so that was something that we were able to do to help remind everybody and keep them reminded of the process as we're going through it and why it's so important. On all of our tube stations too, we've also affixed a little retractable string that has additional red sharpie markers on it as a reminder for when you're sending it to go ahead and put your red line on it. That helps a lot with some of our things but we were still having issues with getting our orders put in quickly enough so that we would have enough time to get the lab processed. So one of the things we decided to do there is we sat down with our emergency room physicians and some of our interventional cardiologists and we developed a chest pain protocol order set just for our nurses. Now this is just a triage order set. If someone comes in and they have some of these symptoms, what we can do bare minimum wise to get the whole process started. So we developed it and on it includes things like the statroponin, chest x-ray, the cardiac monitoring, the EKG, things like that. But what we instructed our nurses was if the physician has not put their order set in within 10 minutes of the patient's arrival and they had complaints of typical or atypical ACS symptoms, then those patients were to get this protocol order set on. If the doctor didn't put it in at 10 minutes, that was the green light for the nurse to go ahead and put it on and then we could get the process rolling. And that really helped us with getting our troponins not only ordered within 10 minutes but then to go ahead and know that was gonna be collected and sent immediately to lab. And that just drastically improved our times. Our turnaround time at the moment is 41 minutes for our initial troponin in the ER. 41 minutes that is incredible because there's so many hospitals out there that felt like they may need to go down the point-of-care testing road when really just digging into a true process improvement of looking what one of my colleagues calls it as a sneaker interface of running the blood down to the lab either through the tube system or down the hallway. A staff member takes it down there. And so really being able to look at each step of that process to identify where improvements can be made. And so often it is in that pre analytical phase. So you guys were spot-on with the developing the chest pain order set that where the nurse is still looking to see did the physician put in the orders and if 10 minutes rolls through then they're putting in those orders. And so that's truly being very aggressive in your process improvement that is so necessary in many instances in order to truly make an impact on patient care and in the process. So in cutting down those delays or eliminating even those delays most often. So that is quite impressive. And honestly none of that improvement that we've had in any of the things we would have talked about would have been possible if we didn't bridge the gaps between departments. Had I been working strictly with the emergency room I wouldn't have gotten labs input about what they needed on the front end to cause improvement on their end. And so I do believe it was one of our lab personnel who suggested a visual cue to help with everything. And our ER director is very big on not wanting to add too much to the nurse's workload already especially when they're dealing with such acute patients and everything's time sensitive. Something as little as putting a red stripe on a tube is easy. It doesn't take any more time. It's not asking a lot of extra of the nurses or staff. And so but it really did cause the drastic improvement in our time. That's great. That is so smart. And it truly is getting you know a different perspective and getting each person coming to the table to say well OK well this is my part but this is what I need. Well I need X Y Z before I can do something else. And so it's just it's really so refreshing to see everybody focused on the same issue with the same goal in mind. But everybody brings a little bit something different to the table and sparking those new ideas and how simple it is for a red mark and a little Sharpie. And so that was so almost a cost neutral. I mean Sharpies aren't that much. And so any way that you can improve processes with little cost and little time or no extra time for staff is a win all the way around. And so that's really incredible. So kudos to you guys. Now I do remember one other really impressive process improvement that has come up through several of our discussions and it was involving the EMS agencies. And so how you were able to expand your P.I. focus into including the EMS for the STEMI patients. So can you share with the participants what was going on with the EMS to make you guys want to look at a process improvement. Oh absolutely. So when I first started into this role it was about it was a little bit before last Christmas starting to this role and I was really starting to figure out what I was doing and looking at all the metrics and seeing what all was being collected. And I noticed that we just didn't have the best times for our STEMI that came in by EMS. This could be a lot of reasons. We are a regional hospital. We're 30 minutes away from a lot of patients from a lot of services that are bringing us patients a lot of our EMS services and trying to think about a way how we could even the playing field and you know just really cut back on these times. And the first thing that I found that had to happen before I did anything else in this role was I had to get out there. I had to meet with these people. I had to get to know them and I had to establish this trusting relationship. I didn't know what the relationship was like before me. Everything seemed fine. Nobody was too disgruntled but really getting out there and talking to them about the things that they're running into or the things that they don't like it really can cause a big difference. From all those little things it's just you know having a 60-second hard stop when EMS brings a patient in. When they bring their patient in our nurses and everybody stops for 60 seconds and give them gives them a chance to just rehash the report, share any additional information, anything that they want in those 60 seconds. No one interrupts them. The doctors listen. The nurses listen. Everybody just kind of listens so they make sure that they're being heard and that we actively are listening to them not while we're doing a million other things at the same time. That was a big improvement with us too. And then I started giving a more timely feedback. They had gotten the little case reviews and stuff like that about STEMI's they had brought in in the past. This is nothing new but I made it a goal to make it more personal and to kind of make it a little friendly competition between our EMS's. I would send them out immediately to all of their directors as the agencies and then we started presenting them in our EMS meetings with the other departments along with trauma and stroke and just different people throughout our region. I then started presenting the top three fastest times of each month of our first medical contact to reperfusion. I put them on a little podium. Their little badges would pop up on the screen during the PowerPoint and they got a kick out of that. Just them feeling so appreciated and knowing that their work wasn't in vain and that we really did appreciate everything they did to them. We understand how big of an impact these had on our patients. Just them getting the recognition. They would do the job regardless but just they held their head a little higher and they wanted to bring us their patients more. They knew how much we appreciated it. It not only improved all of our relationships with all these people but now they care more about the follow-up about what really happened to their patient. I can't tell you how many times a day I have medics in and out of my office wanting to know what happened, wanting to see the cath images, wanting to hear more about their stay and wanting to know what they could have done better. They don't work for our corporation and they don't work for our hospital but they are a part of our team and now they feel like a valued part of our team so they really go above and beyond and they've never told me no to anything that I've asked of them to do for us. What a testimony of building relationships and the value of just providing recognition and that's what it's something so simple but it's often something overlooked in process improvement of just that recognition. I love the the fact that you guys do that 60-second kind of a timeout kind of everybody just stop and listen to the story and recognize you know they do contribute and are partners and valued partners in providing care for those patients and they're the patients are actually the EMS patients before they're the hospital patients and so that really is such a process that needs to be followed across all organizations and I think that that is it ultimately benefits the community because if those EMS units are trusting you with their patients they're gonna funnel many more patients and they're going to be you know sitting in the back of the rig and talking to the patient and trying to you know settle them down because they're in an anxious unknown situation themselves and so just having that positive feedback of hey we're gonna take you to Texoma Medical Center and they're gonna take fantastic care of you and you don't have anything to worry about you know kind of just providing that level of reassurance and having that establish a relationship that you've been able to make with them just speaks volumes to truly the culture of what you guys have been able to accomplish in your community and in those surrounding communities that are all funneling their patients to you guys and so I applaud you guys you guys are rock stars in my book so with that said I think we're gonna be able to close out for the afternoon and we will end there thank you guys for joining us yeah thank you so much

Susan McGowan

Chest Pain Program Coordinator

Texoma Medical Center

process improvement

patient care

cardiac rehab referrals

door-to-EKG times

EMS agencies