Karen F. Clements Interview Transcript

The following is a transcript of my interview with Karen F. Clements. To find links to the audio files and more information about the interview, please click here.

These transcripts are made possible by a gift from the NNEAHE.

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Bonica:	Welcome to the Forge, Karen.
Clements:	Thank you very much Mark. I'm very happy to be here today.
Bonica:	I'm pleased to have a chance to finally interview you since you are the president of the Northern New England Association of Healthcare Executives, one of this podcast sponsors. You are also a senior executive here at Dartmouth-Hitchcock and we’ll talk about both of those. First I wanted to start with your background education. You graduated from the University of Maine with a Bachelor’s degree in nursing. Why did you go to the University of Maine, and why did you choose nursing?
Clements:	My mum was a nurse, and so she was a very large influence in my life both in nursing and Army Nurse Corps. My mom was also an Army Nurse Corps officer. She set the stage very early on what it was like, and she did not want me to be a nurse, she wanted me to be pre-med. She wanted me to go to medical school, so my very first semester I was pre-med at U Maine. I was very quickly realized on my second semester that I wanted to be a nurse. I didn’t really want to be a doctor. I wanted to really care for patients, and I had become a CNA by then, a certified nurse’s aide, and was taking care of patients in a nursing home and just really loved it.
	The University of Maine is also where I got a scholarship to swim. I was a national swimmer. I swam for the University of Maine most of my years there until I got injured, and went to their nursing program. I was the very first class in 1988 to graduate from the Orono program.
Bonica:	As you said your mother was a nurse corps officer. When you graduated from university of Maine, you went into the army and became a nurse corps officer. Were you a direct admission, or did you do ROTC?
Clements:	I was a direct commission in March of 1988. My mum and my father were both army nurse corps officers back in the day. I had a fairly large influence of military in my family. The funny thing is all the men in my family are navy, so it makes for a very fan army navy family.
Bonica:	What kind of nursing did you do, and where did you serve when you were …
Clements:	I started at the Brooke Army Burn Center in San Antonio, Texas. I did a sent with the flight unit there, and got to learn how to jump out of a helicopter and take care of some very significant trauma patients. From there I actually went to Fort Devens, Massachusetts, ironically back to New England. When the storm happened, I was stationed at the emergency department there, and we PORed most of the reservist from new England to go across the seas. Then from there I went to Nuremberg, Germany to serve in ICU during that time.
Bonica:	How was it like to make the transition both to your profession as a nurse, and into the army at the same time? These are 2 important professional identities, what was that like and how did the army help you make those transitions?
Clements:	The army had a very structured preceptor shaped during that time. In fact I went to officer basic course just the same day I took my RN exam, and back then it was paper and pencil, 2 days. The first 3 months, I was just training to be an officer. Then when I received the word that I passed my boards... They station you ... When I got stationed at Fort Devens I had a preceptor who was is senior officer, she was the first lieutenant. I was the second lieutenant, had been in army 2 years. She trained me to be an army officer at the same time training me to be a nurse.
	They have a 6 month new grad program when you first come in to the service, and so I spent 6 months side by side with her learning, how to be both an army officer and a nurse, and learned a ton. In army you have a lot more responsibility than you do in a civilian world. When it comes to patient care and skills, I learned a significant amount while I was in there.
Bonica:	Okay, so more autonomy?
Clements:	A significant amount of more of autonomy. In fact when I transitioned back to the civilian world I had to really curb some of that, because the rules were different. It took a little bit of work on my part to be able to transition back into the civilian nursing.
Bonica:	Interesting. Okay.
Clements:	One more fun tidbit - my preceptor at the time, Lieutenant Laurel Hills is also now here in Dartmouth, and has been in Dartmouth for almost 25 years. 25 years to the day when I came to Dartmouth she reached out to me to be my buddy here at Dartmouth-Hitchcock. It’s a very small world.
Bonica:	That was nice. Did anything surprise you about nursing and army nursing in particular? As you came in, you are making your way, you are learning, was there anything not quite what you expected, not in a bad way necessarily, just different? One of the things I guess I'm interested in is people making transitions into their profession. I’m just curious if that’s …
Clements:	I don’t know anything different. Now that I work … I've been in the civilian world many, many years. I see that the orientation programs now, but nursing is very different now than what it was 30 years ago. When I became a nurse that many years ago your responsibilities were greater, and in the military they were even more. I didn’t know anything different, and as I see the new grads coming in today, we spend a similar amount of time with them, 6 months, but it’s very different, the technology is different, the computer is here. There's just very different. I think what I see the most is the technology, the electronic medical record, the equipment that we use; the needles that we use are far more sophisticated than they were 30 years ago.
Bonica:	You served 3 years on active duty, and then returned to Maine and began a 19 year career at Eastern Maine Medical Center in Bangor.
Clements:	Yeah, I think give or take some years. I think my military career was 11 years total with reserve duty in there. I celebrated 20 years in Eastern Maine. I grew up through the ranks at Eastern Maine Medical Center was going home. I was a new grad there before I went to the military, and also was a CNA there, and my mum retired from there. It was really like going home.
Bonica:	It's more than that. It’s not just ... Okay. Where is Bangor for people who are not … It’s in Maine, but give us a sense where is Bangor, what's that like?
Clements:	Bangor in Maine is right in the center of the state. People call that Northern Maine when it really isn’t Northern Maine. It’s near the middle. It’s about an hour from the coast Bar Harbor. Everybody knows where Bar Harbor Maine is, or Acadia National Park. It’s a cross roads of Canada into New England, we get a lot of business from the Canadian region. We do have electricity. I get asked that quite a bit, it’s quite fun. It’s fairly large; it’s 72,000 people in the twin cities. Eastern Maine Medical Center is a fairly large facility. It’s level 2 trauma center that serves two thirds of the land of massive Maine, about a third of the population.
Bonica:	It’s a teaching facility as well.
Clements:	It is an academic teaching facility. The programs that they serve are primary care, and I believe internal medicine.
Bonica:	You initially came to Eastern Maine as a MEDSURG nurse. This is a role I think most folks have when they think of inpatient nursing. What did you learn during those early years about your profession, and did you have any mentors who helped you absorb that professional identity. You already talked of one.
Clements:	When I separated from the military, I went back home to get back up on my feet and took a position as a med research nurse back on my old unit. It was comfortable. It was easy for me to step into that as I had a young child at that time. My mum was in charge of several units. I worked off shifts from that, but really quickly moved to an emergency department position on nights, because that’s what I did in the military. I was a field trauma nurse, spent most of my career in the ED and ICUs.
	Grew up there, had a lot of mentors. The one mentor that to this day continues to be my mentor is Dr. Eric Steel. He was a primary care physician, but he was in leadership at Eastern Maine through his 20 years, and then he is in a leadership position in Ohio I believe. He was a physician, but a very good mentor. He was my administrator at the time, and helped me grow and mentored me throughout. He's the one that chose me to be the nurse manager of the ED back in 1990, and then I grew from there.
Bonica:	Great. Did you know when you came back to Eastern Maine did you know ... I'm going to go, I'm probably going to do this administration role rather than say go further into a more technical clinical career, because nurses have to make that choice, right?
Clements:	That’s interesting. In the military I actually had gotten accepted into the Nursing Anesthesia School when the war happened and all orders were canceled. I maintained my staff nurse position. At one point I wanted to be a nurse anesthetist, at one point I think I wanted to be a midwife. Then in the military I was in the leadership role most all the time. I was in charge of the crew, in charge of my shift, in charge of my unit, and when I went back to Eastern Maine Medical Center I was quickly recognized to be a charge nurse.
	I didn’t realize that I wanted to be in leadership until I saw that I wanted to see change on my unit. I became quickly involved, and I became in charge of the emergency department. There was a post by the nurse manager to think about taking the position. It was really my mentor Dr. Steel and my nurse manager who was leaving, who really steered me toward that track. I really like to make a difference, and to do that sometimes you have to be in charge to be able to make those differences, and to rally the team to help you. That’s when I chose to go and get my MBA instead of a further career in nursing.
Bonica:	Really? As you said, you made a fairly quick transition from MEDSURG over to the emergency department where you moved up from being staff nurse to ultimately being the department head nurse manager. How big and busy was this ED?
Clements:	The ED at Eastern Maine Medical Center is a 30 something bed. I haven’t been there for several years, but 32 bed emergency department, level 2 trauma center. Saw about 45,000 patients a year, was one of the major referral centers for Eastern and northern Maine, so very busy.
Bonica:	Yeah. Tell us a little bit about nursing in the emergency department, and how this kind of nursing is different than maybe what people think of when they think of say MEDSURG or something like that.
Clements:	Emergency department nursing is not structured. There is no appointments, you never know who is going to come through the door. It’s fast paced. You have to be quick on your feet. You have to have significant critical thinking skills. You work very closely with your partners which are your providers, your physicians. It’s very team oriented and it’s fast.
	We have very short of attention spans in the ED, because our patients turn over very quickly. You have to create a relationship with that patient first in short time period so that they can trust you. Most patients are in extremist when they come to the emergency department. They are in their most acute phase of whatever trauma or disease process they are in.
Bonica:	You moved into a manager role during this period where you are not only supervising people, but you are supervising supervisors. This is a pivotal point for a lot of managers. They tend to go through some real pains as they move into this role. In particular you have to give up maybe some of the things that have made you really successful at that point, because now you have to be focused on helping other folks be successful. Can you tell me what was different for you becoming a manager versus a first line supervisor?
Clements:	One of the most difficult things is that I got promoted from within the ranks. One day I was a peer, the next day I was their manager. Those were some of the challenges in the beginning is to set the bar, set the expectations, and then hold people to those expectations. As you transition from a peer to a leader, those are challenging times. I cut my technical skills. I still practice to this day even in my own role now. That kept me close to the staff and to the issues at hand, and could really partner with them to improve their processes and their care to their patients. I maintained those just because it’s one area that leadership gets criticized a lot is we are too far away from the action. I can’t say that.
Bonica:	Okay, I didn’t ...
Clements:	I know the action.
Bonica:	Okay.
Clements:	Plus I love it.
Bonica:	Yeah. In 2005 you were promoted from being the ED head nurse to the administrator for patient care services. What is that position? What were your responsibilities, and how does that fit into your overall operation of the hospital?
Clements:	As I grew to my nurse manager role, I assumed responsibility of the Urgent Care Center and also in orthopedic outpatient appointment area. Then my mentor Dr. Steel was being promoted throughout the system. He encouraged me to go back and get my master’s in business, which I did complete during that time and that was required to step up to the next role as administrator. The administrator role at Eastern Maine Medical Center was really more of a vice president role, so was in charge of the service line. You worked very closely with your nurse manager of the service line, and your physician leader of the service line.
	I had at that time the emergency department Urgent Care Center, trauma. I think those were the three I started with. I started with very closely with those 3 leaderships teams to develop the service line. In charge of hiring, firing, budgeting, strategic planning, volume analysis. I was able to build the Urgent Care Center that’s located in Bangor Maine. I got to do some construction which I love to do as well, and then just quickly took on more and more service lines throughout my stay there.
Bonica:	How did your leadership style, and how did your leadership develop during this period as you kept taking on more responsibilities?
Clements:	I think sometimes we learn by trial. I made my mistakes, I mentor my new leaders now and say, “It’s okay to make a mistake because you learn from that mistake, and as long as you own it and you move forward those are very important lessons.” Eastern Maine Medical Center is also a union shop for nursing, and so I learned a lot about how to be fair. It’s very important to me to be honest and fair. Those are some pretty strong ethical beliefs of mine, but also hold people accountable to the care that they are giving patients.
	My leadership style changed as I grew and had experiences. I have a very open collaborative style although I can be fairly directive at times depending on what the situation is, and also education. I got to go to the Washington Leadership Academy. We had our own academy at Eastern Maine healthcare systems at that time. We did a lot of training for leaders which I was very lucky to have been part of. Then I became a member of ACHE, and I felt and I knew we were going into get into some of these questions.
Bonica:	Yeah. In fact I wanted to ask you that. At what point did you make the decision to join ACHE?
Clements:	When I became an administrator, I realized I needed to have a professional leadership organization to belong to. At the time a lot of nurses belonged to AONE which is a fantastic organization for nursing. I think I wanted to see the bigger picture. I wanted to be as my role as the administrator I was part of the strategic planning and mission and vision, and also nursing and practice, but it was much larger. I happened to be just reading a professional manual actually and saw an article of that, and reached out, and did some research and joined. The CEO of the system who was new to our system at the time Michelle Hood was a fellow, so she encouraged growth in the college. I think that’s where that led me.
Bonica:	We will talk a little more about that in a minute. In 2010 you left Eastern Maine Medical Center and went to Acadia hospital to be the chief nursing officer and vice president of nursing inpatient care services. What kind of facility is Acadia and how was it different from Eastern Maine Medical Center where you spent the last couple of decades?
Clements:	It was a very different hospital. Acadia hospital is one of the affiliate hospitals of Eastern Maine Healthcare System. I stayed within the system. I had gotten to the point in my career where I was ready to grow and groom. An opportunity to be the CNO came up. Acadia is free standing, 100 bed psychiatric facility. It’s both inpatient and outpatient, both pediatric and adults, and have a very large substance abuse program, something that I had very little experience in as a nurse although our emergency department had a behavioral health hallway and did a lot of acute care management.
	I really was not a psychiatric nurse. I didn’t have my advanced degree in psychiatric nursing. I brought to the table leadership. At the time that’s what they really needed. They needed a strong nursing leader. I actually didn’t apply for the job at first. I had several people reach out to me and I looked into it, and I thought this would be a fantastic opportunity to make a difference. That’s very important to me. In the 3 and half years I was there it was an amazing journey and a phenomenal experience.
Bonica:	What were the key learning experiences that you had while you were there as a leader, as a clinician?
Clements:	When I first went to Acadia it had been under fire for significant injuries to staff, and some low morale and high turnover and quality and all those issues. I worked very closely with my medical director, and my leaders to take some ownership of the hospital and some pride, and really turned the hospital around team. When I left, they were top performer. It’s the only free standing magnet certified hospital in the world.
Bonica:	What does that mean, magnet?
Clements:	Magnet is a nursing excellence label. It’s based on quality and turnover and all that sort of stuff. I taught myself how to be a psychiatric nurse. I had a PhD professor from the University of Maine who mentored me every month, because the joint commission requires you to have that if you are not a psych nurse you are required to have that education. I learned a whole new skill set on how to take care of acute and chronic mental illness and substance abuse, which are plaguing our nation, and it’s within all of our areas now and able to lead that team, not just nurses. I worked with social workers and psych techs and physicians and care managers and nursing to really build a team that provided phenomenal character to mental health.
Bonica:	You are coming in as an outsider, because as you said you weren’t a psych nurse. How did you overcome the … People would know that I'm assuming. How did you overcome that, “Hey, she's not one of us.”
Clements:	One my biggest criticisms is that I wasn’t a psych nurse. One of my biggest strengths was that I wasn’t a psych nurse. People told me that to me frequently, and what I really did is I fell back on the skills that I had leaned over the years of being a leader, and a lot of that is managing by walking around. I round, every single day I get out there, I touch patients every day, I round with staff, I shadowed with psych techs, I shadowed, I served food at cafeteria, I shadowed a house keeper just to learn the roles.
	A lot about leadership is about relationships. It’s about trust. That’s what they needed. They needed someone that they could trust, that is visible, that would then make changes. To make successful changes there needs to buying, and there needs to be the staff want to change for the good. As a leader you have to provide that environment for them to do that. That’s how I led and they had never had that kind of leadership before. I still use those tools to this day.
Bonica:	You joined a senior staff where most of the senior staff, had they been there for a while? You are kind of part at your level, so Chief medical officer, CEO, had they been there for a while or were you the only new addition?
Clements:	No, they had gotten a new CEO about 6 months before that. Typically sometimes you will see the senior staff turnover when you have a new CEO. Most of the staff were new, the senior staff. The CFO, Marie Suiter, was the one who’d been there 15 years, so she was our rock, but everybody else was new.
Bonica:	Okay. How did you guys ... I mean you obviously as a team recognized you needed to make some changes, what kind of strategic decision making did you go through to make that reset the directive?
Clements:	Well, it’s about team building. 6 months after I got there our CEO resigned, and we got … We were all put in more strategic positions to change and make change to the hospital. We were a fairly strong team, and we all knew what our role was. We all supported each other in the changes that we need to make. We just set a strategic vision and mission, and we actually rewrote our strategic mission and vision for the hospital. We had a brand new mission statement, vision statement, and we had buy in to those, people could see the hospital moving. It was really a team effort.
Bonica:	How did you get buy in from the staff for your new vision?
Clements:	You know what the most I think important is the heart to trust senior leadership, and they had lost that. When they started seeing our quality scores go up, they saw our ability to recruit physicians, and our use of locum tenens go down, our ability to provide. We did some major pay restructure which had not been done for a serious amount of time. I remember people who worked at McDonald's made more than my techs that took care of the patients side by side. I made that a pretty strong strategic imperative. As most of us know there's not a lot of money in behavior health, but we did it, and we were able to do that.
	You have to take those baby steps to get that trust from your staff, and when you say you are going to do something you do it, and if you can’t do it you tell them why, and give them that reasoning. I think it was really about trust and relationships.
Bonica:	You left Acadia in 2013 to come here to Dartmouth-Hitchcock. Dartmouth-Hitchcock is located in Lebanon, New Hampshire. For listeners outside of New England, where is Lebanon and what characterizes the area?
Clements:	Well, they call it the upper valley, so Lebanon, New Hampshire is located right on the boarder of New Hampshire Vermont, the right center state pretty much. It’s fairly remote and rural. Dartmouth-Hitchcock is a very large facility in this remote area. It's the largest employer in, I want to say the state, but again don’t quote me. It has its own zip code. As you can see it’s a fairly large facility.
Bonica:	Big facility yeah. I hear there's a college in town?
Clements:	I'm sure no one’s ever heard of Dartmouth-Hitchcock, I mean Dartmouth College one of the Ivy League schools. We are affiliated or have a relationship with Dartmouth College, and the Geisel School of Medicine. We are a very large academic medical center, and have academia in almost every practice area.
Bonica:	There's a number of centers associated with Dartmouth-Hitchcock and Norris Cotton Cancer Center, Children’s Hospital at Dartmouth. What are these and are there other major centers that I didn’t pick up?
Clements:	Those are the more prominent ones. Dartmouth is actually just on its journey to develop service lines. Just in the past month Dr. Brookmyer has announced the development of a dozen or so service lines, so one of those being primary care. The primary care service line, there are 5 campuses to start with Hitchcock. There is one located in Manchester New Hampshire, Nashua New Hampshire, Concord New Hampshire, Keene New Hampshire. We have affiliations in Mt. Ascutney, Vermont, New London, New Hampshire, and Keene as well.
	Growing our system as well as service lines. The Norris Cotton Cancer Center was developed years and years ago. They had relationships with ... We have relationships with Mayo Clinic and Dana-Farber. The Children Hospital at Dartmouth is also very well known throughout the state. We house the only pediatric intensive care unit for the state here. It’s a fairly large program and also the cancer program for kids.
Bonica:	We were talking before we started recording that you have a relationship with 40 other hospitals in the state that refer here, or you help refer around the state. How does that operate?
Clements:	Dartmouth Hitchcock is the only level 1 trauma center in this state, and mostly the region. The next closest one is the University of Vermont up in Burlington, Vermont. We actually have 42 facilities that will refer to us for a higher level of care. We manage that. We have a very robust transfer center that takes all these calls and connects physicians to physicians to make sure we are accepting the right type of patient to the academic medical center. We have now 3 affiliate hospitals and growing our affiliation in our system, so Dartmouth Hitchcock systems. Those are our sister hospitals we call them, and we work within our region to make sure we put the right patient in the right bed.
Bonica:	You came to Dartmouth as the program director for patient placement services which is essentially - we were just talking about it. What made you decide to make the leap from Acadia in the Eastern Maine Healthcare System?
Clements:	Well, Mark, there was always 2 answers to that question.
Bonica:	Okay.
Clements:	I had …
Bonica:	I think I know one...
Clements:	You do know one of them. You know him well.
Bonica:	[laughter]
Clements:	He's been on the show. I had 23 phenomenal years at Eastern Maine Healthcare System. My children were grown and off in college, and realized that it was time for me to grow up and leave home again. To be honest with you, I didn’t expect to be back in Bangor very long when I left the military. I thought I just go back home, get back up on my feet, and go off to warmer climates. I'm really not a winter person. I know you laugh, but I spent most of my life in Northern, but I really don’t like it.
	I had met my now significant other though ACHE as you know and realized, and he is the CEO of one of our facilities here in the region, and realized that life is short, and it was time for me to spread my wings and go try out something different. I reached out to the former CNO here at Dartmouth, and applied for the program director. I had worked in transfer centers before at Eastern Maine. It was a good fit and came this way.
Bonica:	Your role with respect to the system today, is it strictly limited to the facility here, or does your role as the deputy CNO extend to affiliate hospitals as well, how does that work?
Clements:	This is a new structure for us. Gay our chief nurse for the system has been here about 15 months, and has really reorged with her physician leaders to develop service lines. My role as associate chief nurse is actually across the Dartmouth system, not the affiliates per say. One of the other CNO is working with integration of the affiliates, but my work is across to all 5 campuses, and actually beyond. We have in Bennington, Vermont, we have clinics in Plymouth, we have 142 different inventory clinics, so across many, many different sites. My role as the nursing leader stretches throughout the state, both in Vermont and New Hampshire.
Bonica:	Okay, wow. Let’s talk about the structure of nursing here in Dartmouth Hitchcock. You have a nursing chief nursing officer; I called you a deputy, but its associate, that’s the army ...
Clements:	It’s great I know.
Bonica:	Associate chief nurse. There's more than one person acting in an associate chief nurse role as yourself, is that …
Clements:	There are 5 to believe. This is a fairly large system, and with the development of the 12 service lines, soon to be 13, there needed to be some senior nursing structure to be able to support the work of the physician and administrative leaders. We are really moving forward in a triad model to have a physician leader, a senior nurse leader and administrator leader, vice president leader to drive those service lines across our system. For example, we have surgical services at this campus, but throughout the entire other campus as well and they are all fairly unique. Some of these service line development is to bring best practice and some consistency of practice across the system.
	My role ... I have many different areas as you know. I have all of inventory practices, primary care, emergency department, the clinical decision unit, the behavior health program which is going to be a fairly large service line. Behavior health is both the inpatient units here and across our system with population health. We do a lot of work with population health. Care management is now in my portfolio. As we grow care management in the transition of care, our goal in healthcare is to keep patients out of the hospital not in the hospital. A lot of that work is good transitions of care and management and care at home, that kind of thing.
	Another great cool department that’s now growing it’s called emerging care. That’s a fairly new development here at Dartmouth Hitchcock. We've partnered with Microsoft. It’s a virtual clinic with staffed 24/7 by nurses and health navigators to do a lot of home remote monitoring by fit bits and skills and glucometers, also data mining. We are able to provide surveillance on some of our sicker patients to be able to act sooner. That’s kind of a really neat new adventure that we are doing. Then the connected care center as well which is all of our telemedicine in our regional transfer work.
Bonica:	We walked through that earlier. Can you talk a little bit about that because I find that fascinating. What is the responsibility of the chief nurse in Dartmouth Hitchcock system? Talk about you, is your …
Clements:	The chief nursing officer is ultimately responsible for the practice of nursing.
Bonica:	Okay, what does that mean?
Clements:	Nursing has a practice. It also has a scope of practice. Each state has a board of nursing that dictates the practice of that nurse. What can that nurse do? Can they … What meds can they give? What kind of assessments can they do? What kind of discharge training? Can they interview? Can they draw from our line? There's practice, there's also technical skills that they can do. The chief nurse is really responsible for the safety and practice of nursing throughout all the different specialty areas and inpatient and outpatient.
Bonica:	Okay, and I was reading on the nursing pages of the Dartmouth Hitchcock website. There's a page dedicated to the professional practice model, and it talked about role clarity of practitioner, leader decision maker, scientists, and transfer.
Clements:	Correct, so Dartmouth just revamped its professional practice model. Dartmouth is a magnet facility. We are on a journey. We’ve been designated several times. Again magnet is the nurse excellence award, and that is really about quality, safety patient engagement, and staff engagement. The chief nurse is responsible for all 4 of those areas, and they are all very interconnected to the success of a patient’s recovery. As professional nurses we own a lot of that care to the patient. We make decisions everyday based on our assessments. If I assess a patient and find that their vital signs are out of whack, or their assessment is off, we make a decision to follow a treatment pathway.
	We are also teachers. We teach the patient. We teach the family, we teach each other, we teach medical students, so transfer of knowledge. We are constantly transferring knowledge from about patient care and engagement sort of thing. The other things are leadership, that we make decisions where the leader, whether they are primary nurse for that patient who’s taking the lead of care, we are the voice of the patient.
	We are also leaders in our own right. I'm a leader and we practice scientist. Scientist is one people look at, like why are nurses scientists? We are always doing research. Medicine is always doing research. Nurses are an integral part of research. We have a fairly nursing research program here. We are part of large studies across the country. Doing the research is a lot of people’s niche, not a favorite of mine, but I do it.
Bonica:	Right, everybody’s got their thing.
Clements:	Everybody’s got their thing, my attention span is not that long. As a nurse we embody that whole full spectrum, and so Gay’s vision is to elevate the practice of nursing here to be that practice model is that we are those characters that surround the patient to provide that care to the patient.
Bonica:	I also saw something about nursing ground rounds. What is that?
Clements:	Nursing ground rounds are education session that we hold frequently here. They are a certified education opportunity. Nurses are required to get CEUs to maintain their license. They are usually around a topic. We just did one on emerging care. We did ambulatory nursing for the future, and so we talked about emergent care and connected care, and some of the other work we are doing in ambulatory. We are really taking experts from the field nurses, and allowing them to present.
Bonica:	How are advanced practice nurses used in the facility, and where is their presence especially strong, and how has that changed by the way?
Clements:	APRNs in my opinion are the future of healthcare. We all know that medical school, number of students that are applying are down, and we need to make sure that everyone is working to the top of their license. You are going to start to see growth of nurse practitioners, because they can be independent practitioners of medicine. In special states they don’t need oversight of physicians. You’ll see APRNs in many different areas.
	Here at Dartmouth Hitchcock we have APRNs that sit in a clinical specialist role, and they are the consults to the nursing practice to make sure we are doing the best evidence based practice. You see them in every clinic, every specialty clinics, working along with the providers as a team. The team will consist of registered nurses, advanced practice nurses, and physicians. The patient is actually steered to whoever they need to see based on their complaint that day. If it’s a complaint that can be managed by a registered nurse, hypertension clinic, blood pressure, those sort of things, then they see the registered nurse. If they are in critical need, they need to be admitted, then they see the provider.
	They are a very big part of the team. We see them also in leadership roles. They are a very strong force here. We have an APRN and assessment board who just sit on the board of trustees to speak for the nurses and APRNs. There's going to be a growing and need for advanced practice nurses.
Bonica:	Back to the structure of the nursing in the facility. Are all of the nurses in the facility rolled up, do they all, do you all roll up under the chief nursing officer, or they may tricks out and then mix that out. Are there nurses who report to a different line of command?
Clements:	Every single direct care nurse, a registered nurse, unregistered nurse have some sort of line to the chief nurse. In ambulatory it’s a fairly new structure. We are still trying to tweak those lines, so a lot of them have a major supporting. They report to myself and to a practice manager who's in charge of the practice, so that’s the business end of the practice. Inpatient nursing have a nurse manager who then report to a CNO who report to Gay. There has to be some sort of line from that registered nurse up to Gay.
Bonica:	Going back to your own development here at Dartmouth Hitchcock, you weren’t in the program director for very long, and you moved up to be the director of emergency department and patient placement services, something you are kind of familiar with. How were those roles different here than they were when you performed them in Eastern Maine?
Clements:	They are not much different at all. In fact Dartmouth Hitchcock is very similar to Eastern Maine Medical Center just based on its roles, the type of medical center, the one thing that Dartmouth has is the huge academia part of it that Eastern Maine didn’t have. The role is very familiar for me, and I actually wrote the role when I came. They were in need of a leader in the ED and I have a lot of experience in that area, and so I wrote the role of director of emergency inpatient placement which fit very well because 40% of our hospital admissions come from the ED, and piece and place that works on all that. It seemed like a very natural progression to do that role.
	Not much different, again had to really learn the academia part. We have an emergency medicine service that has interns and fellows which I didn’t have at Eastern Maine. That was a new kind of thing I had to work through. Leadership is leadership, and it’s based on the culture here. It’s a different culture here at Dartmouth.
Bonica:	After a little more than a year you were promoted to be the administrative director for ambulatory and physician practice nursing service community. Describe that role.
Clements:	When Gay first came here in August of 2014, she spent a lot of time in the ambulatory arena, and quickly realized there was no nursing structure or leadership in ambulatory. That’s what the position, it’s an administrator director which again is kind of a like a vice president role that supervise, put under senior nurse at the table in ambulatory and primary care which included the ED as well. The emergency department is still outpatient ambulatory.
	Really it was a promotion and again one of the reasons I chose to work with too is I knew there would be lots of opportunities for growth here. I was very privileged to be asked by Gay to assume that role to start elevating nursing in the ambulatory arena.
Bonica:	This was not a structure that was in place before. Why did Gay look at it and say we need this? What was the importance? What was the strategic value of doing that?
Clements:	Healthcare for years has been focused on inpatient arena. The structure for inpatient is very well established. It’s only been over the last 4, 5 years with population health in Obamacare that we are really looking at the ambulatory arena to lead healthcare. We need to keep patients healthier. We need to do more population health; we need to keep them out of the inpatient arena. We have grown our ambulatory practices significantly over the last 4, 5 years.
	Like I mentioned Dartmouth alone is 142 clinics, not locations, but clinics and there's nursing in all of that. Gone are the days where you have just your physician and your MA. The nursing has assumed a lot of that practice in ambulatory, but no structure. There really wasn’t any leadership structure in the ambulatory, so hence why Gay formed this role.
Bonica:	As a senior executive, you are involved in corporate strategy. How would you define strategy, and can you talk about the strategic planning processes you’ve been involved in, in the past, and how you’ve seen those processes change and evolve?
Clements:	They certainly have evolved. We can no longer see or strategically plan I believe more than 3 years out. Here's a guide to do 5 year plans and 10 year plans and you can’t do that anymore. In fact, most strategic plans are 3 years, are typically 3 years, 18 months to 3 years. They are evolving. We've been through several strategic planning sessions here at Dartmouth as the service lines develop. We just had a full day’s primary care strategic plan is really to look at population health. We got to put the patient in the center and what does that patient need and how do we get there, but also including staff engagement and physician engagement and also workforce.
	We are now heading into some of the worst retention times or nursing shortage and physician shortage times we've ever seen. Our population is growing; our baby boomers are hitting our healthcare system. I had statistics say the other day that 10,000 people every day turn 65. The need for healthcare is going to explode still over the next 20 years as the baby boomers use the resources in our system.
	You have to strategize, how do we best surround the care of that patient, who's the best person to provide that care? Working at the top of their license is a key conversation now. You have nurses doing things that aren’t nursing that can be done maybe by someone at a different level of care. Those are just as we look at our dwindling resources, our dwindling beds in the nation, our inpatient beds, a lot of hospitals are closing based on financial need etcetera. Population health at New Hampshire is losing its middle class, its generation that provides more growth to the population. Our pediatric services and our OBGYN and our delivery services, where should we provide those? It’s a lot of that kind of thing.
Bonica:	Have you seen it done differently in different places, and is there a technique or a model of strategic planning that you like?
Clements:	You know I think it’s the culture depending on what culture you are in. There's also the flavor of the month, what's the big hurrah today. Moderators are always good to keep the flow going, somebody who's not attached to whatever. An outside moderator I believe is very important to keep the pace going, to keep everybody focused because we all can get very tangential and often for hours you can do that.
	I think putting goals up there, having a moderator, looking at the big picture, the healthcare picture, having someone who's very educated on healthcare politics and economics is important. Nursing tends not to be that way. I’ve educated myself on that, not something I would like to do either but it’s important and we all know. Those things are I think critical to the strategic planning.
Bonica:	Big picture.
Clements:	One more thing I'm going to add to that. You have to have the players at the table. You have to have a senior nurse at the table. Nurses can make or break your hospital or your healthcare or your clinic. You have to have a physician at the table who can speak for their part. Obviously the administrator person at the table and a lot of times people will forget that you don’t need a physician, or you don’t need nurse, but you are going to need this big strategic plan for the healthcare of the patient. I've seen that happen as well.
Bonica:	Big picture, where do you see healthcare organizations going in the future and how is Dartmouth Hitchcock changing to meet those strategic changes that you’ve been talking about.
Clements:	Well I think, now that we are heading into an election year, we are going to see some changes to Obamacare, but I don’t believe that’s going to go away. I believe that we are headed in the right direction for population health and maintaining the health of the patient, and keeping them out of the facilities. End of life care has got to change. We spend way too many healthcare dollars, and we don’t respect the elderly, and we don’t allow them to die here in this country. I think end of life care we have to focus on, we spend a significant amount of our healthcare dollars on that.
	Primary care and population health, I think substance abuse is a huge, huge issue for our nation on our state. Behavior health and substance abuse, if we don’t get that a handle on that and incorporate that into our population health, we won’t be successful either. Dartmouth is looking at all of those areas which is exciting. We are building a hospice. We got a donation, $10 million anonymous donation to build the hospice hospital right on our outer lane. We hope we are going to be able to provide it. There’s not an area or place where people can go for their end of life. It’s very difficult for families.
	They get admitted to critical care units and other units, where we do things to them that we shouldn’t. That’s great. Behavior health is a huge planning committee to work with popular health, to work on our substance abuse issues, and education in the communities for that. Then the service line development I think is going to be important as we look at streamlining our processes and our best practices to make sure we are doing those things the best quality is important, and our affiliations, affiliating with facilities that can provide a niche. So Mt. Ascutney is one of our affiliates and they have a very beautiful rehab unit. We have an inpatient, we have a hospital that works with us.
	Tasha Medical Center is a community hospital and can expand their beds up to a 100 inpatient beds. We are full most to the times; we can have a release valve, and keep some of those lower acute patients in the outside. Then New London who's really growing to be like an orthopedic part. I'm not sure that’s official, but you know there's quite a bit of orthopedics going on and on, and so affiliating with niche hospitals that can offload some of our specialties, but be good at it, be great at it.
Bonica:	Let’s transition to talk a bit about leadership. What would you say is your leadership philosophy?
Clements:	My leadership philosophy is making a difference every single day, whether that’s in the lives of patients, it might be a warm blanket for an elderly person, it may be active listing to a staff member who's going through a tough time, but it’s really having relationships with my staff and my leaders to be able to give them the tools that they need to do. It’s really about making a difference. Keeping myself educated to provide them the tools that they need, and the direction that they need, but really to mentor them and to grow them to make a difference.
Bonica:	What would you say are the characteristics and behaviors of a good leader, and how do you aspire to those yourself?
Clements:	A good leader must walk the talk. They must be a visible leader. They must have active listening skills. Relationships again, I've said this before, relationships are critical when it comes to leadership and being able to develop those and maintain that trust. Ethics is extremely important to be a leader, being open and honest, and have that kind of value based system. I think those are most of my foundation. I try to do. I can always listen better. Most of us can always listen better.
Bonica:	Yeah that’s pretty universal.
Clements:	I try to be better at that. I think my team will tell you I'm fairly approachable. You need to be approachable. You need to be humble and remember that we here for the patients.
Bonica:	Can you give me an example of a difficult leadership lesson you had to learn maybe the hard way. Maybe something that didn’t go as well as you had hoped, and maybe you learned from it to change something.
Clements:	Absolutely. You never assume. Don’t ever assume anything. Always, always get the other side of the story, because you know there's always another side and the truth is in the middle. That’s bit me a couple of times. Never use email for any type of critical conversation. We've all made that mistake as well I think. Just don’t ever assume.
	There may be something else that’s going on. Always get the full story before making a decision. Don’t knee-jerk. That’s something I've had to discipline myself. I'm in trauma here and I respect their counsel, we move fast and think fast. Over the last 20 years I've really stopped and I actually pushed back from the table and actually think before reacting. Those were some of the things I've made many mistakes on and been called on before.
Bonica:	Can you give me an example of a leadership challenge that you are particularly proud of having met?
Clements:	Being a chief nurse of a psychiatric hospital that I had no idea what I was doing. In psychiatric world you know how to be a good leader, but certainly did not know how to take care of a psychiatric patient. I'm very proud of the work that I did at Acadia with my team there. It was a … It brings me back very … Makes me very proud.
Bonica:	What do you look for when you are hiring leaders and evaluating them as well?
Clements:	Some of the same things I've already talked about. Being open, honest, walking the talk, being visible, engaged, very engaged with their staff and with me, being open to constructive criticism and feedback, and working with that. That’s one thing that I've been able to get my whole career as a great manager who would say, “Hey look, you need to work on your meeting face. You show your emotions throughout this meeting, everybody knows that you’re …”
Bonica:	Your meeting face is like that.
Clements:	Your meeting face, we used to call the meeting face. I’m a very expression face and I had to really work on that meeting face. Being able to take constructive criticism and grow with that. Allowing people to fail, it’s okay to fall down and scrap your knees. I let my leaders fall down as long it’s not in the greatest area then I let them do that. They’ll reach out later and say, “Oh was that one of those learning days today,” and I’ll be like, yup it is. Letting them ride their bike and fall off of it every once in a while. I expect my leaders to mentor, because we all have to be mentoring the next leaders in this healthcare world.
Bonica:	We talked about at least a couple of mentors you’ve had. How important is the mentor relationships since you bring that up?
Clements:	It’s critical. It’s critical whether you are a direct care nurse or you are in leadership, having a good strong mentor who allows you to ask stupid questions and fall down and guide you and provide you with the tools that you need, and the education that you need, allow them to watch you perform something. I sit with my new leaders and go through very difficult conversations with them, and teach them that it’s not always about winning. It’s about how you get the nurse to grow or the staff member. It’s not always nursing.
	It’s important those qualities are so important and having someone that you can go to and ask those questions, and have an office where you can just go and vent and be angry for a minute, not out on display out on the unit, but you got to have a safe place where you can go and just blow off steam. That’s very important. It’s going to be respectful obviously, but people know that there's an office you can go to and just loose it per say. It’s critical to be successful.
	I feel that those who don’t have great mentors and having to struggle, sometimes, you lose that emotional intelligence that you really need. Emotional intelligence is critical to be a good leader, and being able to engage with other people.
Bonica:	What is emotional intelligence for people listening?
Clements:	Emotional intelligence is all that we've talked about. It’s the ability to be engaged and real and build those relationships and be part, have empathy, all those kind of characters that are crucial to being a strong leader.
Bonica:	You mentioned you had a physician who was kind of your mentor. Was he a supervisor as well?
Clements:	He was my supervisor for a period of time.
Bonica:	Okay. Do you think it’s important to have mentors outside of this supervisory chain? I mean, clearly mentoring is an important function for a supervisor, do you think it’s important to have mentors who are outside of your supervisory chain as well?
Clements:	Absolutely. Having a coach or an outside view coach who can give you … I encourage my staff to connect with a leader if they are struggling with the communication style, and I'm not in every single meeting with these people. I’ll say, “Find someone that you trust in your peer group that can give you a signal or give you some coaching lessons after that meeting of how you presented yourself, or how did that go to get that feedback.”
	I mentor people who live in New York. I mentor people back in Bangor and they’ll call me and present a difficult situation. They’ll ask me what I should do or what I would do, and I would always say what would you do and talk me through that. I absolutely agree with you out of your direct supervisory line mentorship.
Bonica:	Does Dartmouth Hitchcock have a formal mentorship program.
Clements:	We do. We actually send our staff to the Dartmouth TDI institute E-coach to coach, which is a in person and online coach to coach program where they pair them up with somebody else outside their venue. It’s fairly cool program. It’s about 6 months. I have 2 leaders that are in right now, and 2 more going. We have outdoor outside coaches that get assigned to certain level leaders that can actually be outside coaches if a leader needs one. Gay is actually taking the Yale coaching class or whatever that is. She's always encouraging people to have that coaching ability.
Bonica:	It’s cool. What is organizational culture and why is it important? You’ve worked for a number of organizations in progressively higher positions of authority, what aspects of organizational culture are particularly important to you, and how do successful leaders shape organizational culture?
Clements:	That’s a tough question. Culture is so nontangible, right?
Bonica:	Absolutely.
Clements:	It’s the way that plagues fields when you walk in. It’s the way people great you in the morning, or how the lunch people look behind the lines, it’s all that intangible stuff and it’s different wherever you go. Eastern Maine had its own culture, Acadia had its own culture, Dartmouth actually has its own culture on each campus. The Manchester campus has a very different culture than the Concord campus. Then Dartmouth proper, we call it Dartmouth proper has a very strong physician centric culture, because it’s an academic medical center.
	Several years ago when I first came here, it's just was starting to make its culture shift to be more of a team culture not very physician centered. Every single physician was made surrounding the physician, and not the rest of the team. We are still feeling that. Dartmouth as seen with Eastern Maine, there's a lot of longevity. There are people who have worked here for 40 years, 30 to 40 years. When you get that sort of indoctrinated length of tenure for people, that builds a culture, the matriarchs and patriarchs of Dartmouth Hitchcock.
	Culture is a very interesting thing. It’s very important as you try to change the direction. As we are looking to change our strategic direction, it’s like turning that titanic through sludge, because you’ve got to get the culture changed to support that new direction. Being nimble and quick and adaptable, they are not always words that are used in a culture. We like to be no change and that’s healthcare in general. We don’t like to the change. We just like to be just the way we are. That’s why we are so behind the rest of the other industries is because we don’t like to change.
	It’s an interesting culture. You can feel it sometimes when you walk in a facility, what the culture is. Whenever I go to a new facility, I will just sit in the cafeteria and just listen and see and watch. It’s very interesting. You get most of the culture from there.
Bonica:	Yeah, okay. That’s something to write down, that’s a to-do. We talked a bit before we started recording about women in leadership. Can you tell me a little bit of your experience being a woman and being in leadership roles how you think maybe that’s different for you than it would be for a man who might have sat in the same position?
Clements:	Well, I think historically, women and men are treated differently in leadership. That’s well researched, that’s well documented. I think my tuck has been a little different because I started in the military, and my husband at the time; we started at the same time. We were both second lieutenants, but he was given opportunities that were for men to go out in the field and do field things. He got promoted first. I've been part of that kind of culture since the early on of my career.
	Leadership roles in healthcare women are growing stronger in leadership as our healthcare systems are looking to the clinical people to lead facilities. Typically in my career you know sometimes I was a nurse and I was a woman, so the opportunities may not have always come way, but I had a fantastic mentor who was a male and a physician. I think I got special treatment or something, I don’t know.
	I have been the victim of disparity of pay and advancement just based on because I'm a woman, and I'm a nurse. I think that’s changing, a lot of healthcare facilities are selecting clinical people both nurses and doctors to lead their facilities. Nurses are what, 80% women, so the odds of that happening. I think we have a long way to go to get to equality of leadership, whether it’s in healthcare or in other industries with men and women in pay. I hope someday it gets that way. I'm also 6 foot and I come from a military background. I probably have a little bit different presentation than some. That’s helped me I believe in my career.
Bonica:	I have been reading Sheryl Sandburg’s book Lean In, and about 80% of the students in health management policy, the program that I teach into our young women, so obviously one of the issues that Sandburg talks about ... It's not the only one, is this issue of work life balance. You raised a family, you are married, and you have worked your way up into senior executive positions. How did you make all that work? What advice would you give to young women who are looking to come into the healthcare field, and wanted to have it all like you do?
Clement:	What advice I give to my leaders every day, there's no one else that’s going to tell you to balance your work life. There's just no one. You have to do that. What made me successful is that I had a strong support system surrounding me that helped me with the kids. When I chose my first leadership position, my son was going into kindergarten. Before that I worked strictly nights. I just so I could be home during the day, and we took turns, that whole thing. The only way I could do that is that my mother and I was able to get them off the bus and bring them into town to meet if they had a doctor’s appointment and that kind of thing.
	No one ever told me that … No one would ever say, “Go home clement, it's seven o'clock,” every single night. It took me several years to figure that out. Part of my mentorship is to really instill that work life balance. It's about developing a partnership with your partner, whoever that maybe where are your career paths, where are your goals, working towards those goals. Everybody is different, working with your children. I went back to get my masters when the kids were young, but we would do our homework together at night.
	You have to just use what available time that you have to incorporate whatever you are doing, whether you are going back to school or you are in the new leadership job is to remember that the work will be there tomorrow morning, prioritize your work. Life is a gift. Every day is a gift and don’t ever let one day go by without really remembering that. I say that personally that you have to prioritize that.
	There’s always going to be days where you are in the office for 13 hours, or 14 hours. Okay joint commission shows up at your hospital, guess what? You are going to have a very long day. You have a flight in your OR, you are going to have a very long day. Typically the work that we do as leaders unless it's direct patient care, you need to be able to prioritize what that work is and get home for dinner. I stress that, dinner time is very important. If I say anything, always have dinner at the table, always talk about your day with your family, my kids know that. We still sit at the dinner table when they come home. It's very important. Just take that time to make sure you have dinner together.
	Now, my husband and I have coffee together because we don’t sometimes see each other during the week in our roles. We actually have coffee pretty much every morning of the week.
Bonica:	That's nice. As I mentioned at the beginning, not only are you an executive, but you are the president of the Northern New England Association of Healthcare Executives, the local chapter of the American College of Healthcare Executives, ACHE that we mentioned earlier. You mentioned you became involved in ACHE early on when you had made the decision that you were going to pursue an administrative role. How important do you think professional associations are for executive development? How important is it, has ACHE and Northern New England, the Northern New England chapter been in your career development?
Clement:	It's critical, 10 years ago when I decided to join ACHE, I knew I needed education. Just like as a nurse, I went to school for years to become a nurse and I even to this day have to have ongoing education to keep my nursing skills up to date and pertinent. Healthcare leadership is no different. You have to educate yourself. You have to expose yourself to new education. You have to keep yourself up to date on emerging trends in healthcare. ACHE does that. It’s the professional organization that keeps us up to date in our strategic visions, in our education on how to deal with some of that stuff.
	The other big piece of ACHE is the networking. I have colleagues all over the world really that I can network with and reach out to, to say, “Hey I'm dealing with this particular problem, you’ve been through that, how can I learn from you?” We are not here … When I first joined ACHE, I was one of the very few nurse executives in ACHE. I remember Tom [Delon 01:04:34] asking me to recruit a nurse over here. He wanted to grow the ranks of nurse executives and physician executives since I've done that. I've actually recruited every year recruited a nurse to become a fellow. It's grown in its ranks.
	I have I believe achieved my milestones because of the education and opportunities and networking and mentoring from the chapter, and from ACHE, the big ACHE. Also I met Peter through ACHE. Most people know, my husband we met through ACHE as well. We are one of the ACHE couples that people talk about. We had very similar goals, and when it comes to healthcare we, it’s really kind of funny go home and have dinner time conversations. I encourage everybody to get involved in your own professional organization, whether it's ACHE or AONE or HFMA or whatever other organization there is.
	Then I joined the board. They asked me to join the board back in 08 or 07 I can’t remember. They wanted, the New England chapter is made up of Maine, New Hampshire and Vermont and I was in Maine at the time, and we try to split our board members up to have a couple per state. I quickly took over the education chair position, and was able to plan all the education events and plan the parties is what I call it.
Bonica:	It's a good party by the way.
Clement:	It's a great education. We are really growing our education. It's really fun. It's fun and the networking is amazing. When I came to Dartmouth, I had been at Eastern Maine for 23 years. When I came to Dartmouth, I knew most of the CEOs in the region because of ACHE, and because of our regional meetings I had connections here. I knew the CNOs and I knew most of the CEOs. It wasn’t unfamiliar for me to come to a new role in a new state because of the networking I had done throughout ACHE. I came, you know, I just knew that place was great. Then I was asked to be president, elected the president. Here I am.
Bonica:	You are actually winding down your … You’ve been in the position almost 3 years.
Clement:	Nope, I just have one more year of presidency. Presidency is 2 years, then I will be past president. I am grooming my replacement for education chair. We are excited about that to have a new person. I've been doing it for 8 years. It's really exciting to do that as I will continue to grow in my role. Through ACHE I will try to stay connected. I am participating in their mentoring program; I participate in the resume review. I really try to give myself back. I think that’s part of being healthcare leaders giving back.
Bonica:	We try to encourage the young students in my program to join ACHE. Why would it be important? If you are an undergrad, you are 21, 22, just getting ready and you want to go … You know you are going into healthcare administration, why should you join now rather than waiting till 5, 10 years?
Clement:	Oh, gosh. Let me list the ways, exposure, networking, resume review, opportunity, internships, education. I mean there's just so many of access to all the resources online, the websites are very robust websites, has online series and education series, job searches, resume review. I mean it's just … It's really powerful tool.
Bonica:	In closing, what advice would you have for young people looking to go into either the nursing field or into healthcare administration since you span both of those with your career?
Clement:	Don’t be afraid to do something that scares you. Step outside your comfort zone like I did when I took over psychiatric hospital. That was far outside my comfort zone as I could have gotten. Volunteer, for everything and anything, get out there, get exposed, ask to be on committees, be part of your professional organization, be part of volunteer for your local community, be part of some sort of service club whether it's Rotary or Kiwanas, but be part. That will expose you. If you are going into healthcare, that’s what all that means, is taking care of our community and our patients, and how can you lead that if you are not part of it?
Bonica:	Thank you so much for your time today.
Clement:	Thank you. This has been great.