Peter Wright Interview Transcript

The following is a transcript of my interview with Peter Wright. 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, Peter. You're originally from Connecticut, but you went to Lyndon State College. Where is Lyndon State College and why did you choose to go there?
Wright:	Lyndon is in what's called the Northeast Kingdom of Vermont. It's actually in the town of Lyndonville, but the three northeastern counties of Vermont make up the Northeast Kingdom. I ended up there just after high school. I was somewhat prompted by my uncle who was also a graduate of Lyndon State. It was an interesting dilemma for me. I graduated from high school in 1990, actually, living in New Jersey, and was confronted: do I go to school, or do I go into the military? Where I was from, there was a heavy Marine Corps influence, and so I was being courted by a Marine Corps recruiter and was absolutely enamored with the fact of joining the Marine Corp and being a helicopter pilot.
	My uncle, at the time, didn't think that was a good idea given the advent of the first Gulf War and flew me up to Burlington and put me in his car and sent me over to Lyndon State where I had an opportunity to take a few classes, spend the weekend there, play basketball with the basketball team, and take a couple of runs at Burke Mountain. I came home and said, "Forget the Marine Corps. I'm going to college."
Bonica:	You studied business administration while you were at Lyndon. Did you know you wanted to do healthcare administration while you were doing that? Or was it something that came after?
Wright:	Absolutely not a clue. I actually went in as an account manager and, within the first semester, decided that wasn't for me and so switched over to business. Lyndon has a big ski resort management program, so when I graduated I ended up in the ski industry through some alumni contacts. I never knew that I would end up in healthcare really until just before it happened.
Bonica:	When did you get your first job in healthcare?
Wright:	In 2001, I applied and was hired for the director of marketing and public relations at Copley Hospital in Morrisville, which was a part of Copley Health Systems at the time, which had 11 different entities. That was via and alumni friend of Lyndon who was working there who thought I'd be good in that role.
Bonica:	You'd been doing marketing work prior to coming to there?
Wright:	Actually I was living two parallel lives. I was working in marketing and PR for a variety of different firms. First in the ski industry, and then for an organization called the Littleton Coin Company. I was also a police officer at the same time. I would go to work at one of those business based organizations in the morning and then put on a uniform and patrol the streets at night.
Bonica:	That's an interesting preparation for being director of planning development for a medical group. What was that job? What was involved in doing it?
Wright:	Copley Health Systems at the time was an 11 business entity, and I was working for the largest entity, the hospital. I grew pretty quickly in that group and the CEO seemed to recognize some talents that I have and promoted me to the system level where I worked in marketing and then planning. We put together a strategic plan that essentially disassembled that system, broke the long-term care wing off to a separate entity, the mental health organization off to a separate entity, and eventually some of the physician practices into a federally qualified health center.
	We took what was a big system and we boiled it down to a little less than half of the number of companies. As I got involved in that strategic plan, healing bring it to fruition, I got involved in government affairs as well through my public relations work. Then that just naturally evolved into operations. I was in that position for about six months, and I remember driving to work one day and I was so excited to go to work. It dawned on me that this is what I was going to do for the rest of my life.
Bonica:	You stayed there until 2007, and after that you went to be the chief operating officer of the Littleton Regional Hospital. Tell us a little bit about what you did as COO in Littleton.
Wright:	A quick jump back to Copley. When I knew I wanted to say in this industry, I got some good advice that said volunteer, get involved in operations. That's what you need. You need operations experience. I managed a few physician practices and we acquired an orthopedic practice. When the opportunity in Littleton came about, it was very heavily focused on working with their multi-specialty physician practice group and growing and enveloping and improving the systems and drawing on my talents from the ski resort industry about customer service and improving service there. That played a big role in why I went to Littleton and I think why I was selected.
	I got to Littleton and, interesting, it was the same CEO that was at Copley, so we had known each other for a long time. There's a great benefit about knowing someone and knowing that you can work well. A lot of symmetry in our relationship. We did some great work in Littleton and still going on. Building of a 66,000 square foot medical office building that was 75% more efficient than the other medical office building due in large part to it being heated and cooled through geothermal. Intense recruitment. I think at one point we had up to 14 new physicians coming on board in one year.
Bonica:	Was the system growing that fast?
Wright:	Absolutely. Littleton really had evolved during that time as a regional provider. They are a critical access hospital like all the other hospitals up north, but they were really a critical access hospital in a bigger hospital skin. Where most critical access hospitals suffer from lack of services, Littleton was able to position itself as a regional hub because places like Concord, or Manchester, or Dartmouth-Hitchcock were up to two hours away, that we were able to attract more specialty work really. There's a lot of investment in primary care, but also an investment in medical specialists and surgical specialists. That's how it evolved into what it is today.
Bonica:	You mentioned the idea of a critical access hospital, and I know this is a critical access hospital here as well, so let's talk about that for a minute. What is a critical access hospital? What makes it different? Why would the hospital want that designation?
Wright:	In the early to mid-2000s, the federal government recognized that sustaining healthcare in rural environment was critical and they came up with two programs. One was federally qualified health centers, which is really for primary care clinics, and that actually came a few years earlier. The other designation was critical access hospitals. There are four major requirements.
	One, you can't have an inpatient census more than 25. The moment you add your 26th inpatient, you have to write a plan of correction and why did that patient have to come in and what are you going to do to get your census down. The average length of stay cannot exceed 96 hours. You have to be 35 miles away from another hospital. Now, at first blush, everyone will say, particularly in the state of New Hampshire, that's not the case for any of the critical access hospitals except for upper Connecticut. The fourth was the magic wand of the governor. The governor of each state had the right to just bless a hospital as a critical access hospital. You meet those requirements and what you're able to do is get cost based reimbursement for your inpatient Medicare and Medicaid patients.
Bonica:	How is that different from what other hospitals get then?
Wright:	All the other hospitals are paid on a what we call PPS, perspective payment system. They get paid for a DRG. You come in to have your knee scoped; it's a flat fee. You get paid no matter how long it takes. If you're there for a day; good for the hospital. If you're there for five days; the hospital really absorbs all that cost for a fixed price.
	At a critical access hospital, if you're a Medicare patient, we would get 101% of our allowable costs. At the end of the year, we do a cost report with Medicare and some costs they allow and some costs they don't. It's not everything on the budget. Then they look at those allowable costs and say, "Medicare represent 40% of your business and Medicaid represent 10%-12%, and so we're going to pay you 101% of those costs for 55%," or whatever the total percentage is. We settle those cost reports, they're a couple of years behind, and it results in millions of dollars more to the healthcare system.
Bonica:	As the COO, what were your responsibilities? What did you really focus on?
Wright:	I had responsibilities for three divisions. All of our employer physician practices, as well as the liaison with non-employer physician practices. Our non-nursing clinical group, so lab, radiology, pharmacy, respiratory therapy, and our support services group. Environmental services, engineering, volunteers, and our culinary group.
Bonica:	You're not a physician, but you were managing the physician group.
Wright:	Correct.
Bonica:	How does that work?
Wright:	Some people think that's a good thing and some people don't. It doesn't necessarily follow the lines that you would think. Today I think that current management practice is really a diad or a triad. I had the administrative responsibilities. Today, healthcare is a business and it needs to be very closely managed and monitored. We have a special group of clinicians that have a very unique and intense set of skills that I don't have. Closest thing I have to it is I was an EMT in high school and college. It's a partnership. Like any good partnership, you work together with somebody. Rather than being a leader that says, "This is what you're going to do," you collaborate.
	I collaborated with physician leaders and I collaborated with nursing or other clinical leaders and we took that balance of what's the right business decision and how does that work clinically and work together to make the changes or to grow in the way we needed to grow.
Bonica:	How did your experiences, in your opinion, in Littleton as the COO, prepare you to take the role that you have today? What did you learn about managing a hospital? What did you learn about leadership that really prepared you for the role that you took here because, from Littleton, you then came to take on this role.
Wright:	I think it's not just at Littleton. I think that every step in my career I learned something that helps me today. Even as a former law enforcement officer. There are things that I learned on the road and what people deal with before they get to the emergency department or what they struggle with after they leave. I take that experience, my experiences from the ski resort industry, and even working for the Littleton Coin Company in direct marketing; it all plays a role in what a CEO's job is.
	Obviously as the COO I had a lot of the hands-on direct management for operations. I think the thing that prepared me the most was having a great mentor. His name is Warren West. He was the COO who originally hired me in Morrisville and then hired me again in Littleton. Felt that I had the potential, and so he mentored me, he gave me great opportunity, he provided me the freedom to take manageable risks and fail and learn from that. He invited to meetings and strategy sessions with the medical staff that you wouldn't traditionally see for a COO. As a result, I got about as ready as you can get, which isn't nearly ready to take the job. One of the things I've learned as the CEO is you think you're ready, and then you get there, and it's a whole different story.
Bonica:	You mentioned mentorship, and this is a theme that I wanted to come back to, and we will come back to it. One of the things you said was he allowed you to take manageable risks. What manageable risks? Can you give a specific example that you were allowed to do that maybe went a little beyond what you had done before?
Wright:	Sure. Something very basic. In our physician practices the traditional model is a physician medical director and then a practice manager for every practice. I found that to be very inefficient and allowed itself to breed inconsistencies across the practices. What my proposal was not to have a primary care team, a medical specialty team, and then a surgical team in terms of management, nursing support, and physician leadership, but to have a set of leadership across all the practices and to really integrate them which, later on when we built the medical office building and we brought everybody in and they were physically integrated, turned out to be a smart risk to take.
	We had supervisors and leaders that crossed the spectrum. They managed function as opposed to a particular practice. We had a primary care practice manager and a specialty practice manager, but underneath those two were a broad based spectrum of clinical and non-clinical leaders that reported to both of them at the same time. We had a clinical informatics that handled IT integration across all the practices and they were responsible to the two managers to make sure that everybody was trained equally and that the level of IT adoption was consistent with what our plan was across the organization.
	We had an operations supervisor who managed all the non-clinical staff so that a front desk reception in primary care could easily fill in as a front desk receptionist in orthopedics. Then we had a clinical supervisor whose job it was to manage the competencies and work of all the clinical staff in the same way. A primary care nurse could very easily move over to occupational medicine or to neurology and be able to fill those roles. As a result, we needed fewer staff. We have a great level of professional fulfillment to the staff that were there and the propensity for growth.
	It was a big risk that was not supported by the medical staff until they saw it work, until they saw that this is great because when my medical assistant is out, then I can have a medical assistant from another group who knows how to support me and I don't have to go thin for the day.
Bonica:	You proposed this to your CEO at the time and he said, "You can give that a shot?"
Wright:	He gave me the hairy eyeball at first. It was a rough road and it wasn't a perfect execution. There were certainly pitfalls. In our position, you have to listen to your medical staff. When the medical staff pushes back, you have to listen to that and take measures accordingly. It was an up and down, but the end product and how they function today is far more efficient and more productive. In the end, I think the medical staff is satisfied with the level of support that they get and the level at which allows them to function so that they can be better providers in their own mind.
Bonica:	You mentioned it was a manageable risk. This was one of the things that you said the CEO was good at doing as a mentor was giving you the opportunity to take these manageable risks. How do you identify manageable risk? How would you define that?
Wright:	I think when there's a problem we'd come to the table with a traditional this is how we should solve it. I've been through several creative thinking exercises which is come up with the traditional answers and then keep pushing, and you come up with the ridiculous answers. Once you get through that exercise, you start merging the ridiculous with the traditional and that fosters a lot of thinking at the creative end. How do we make the ridiculous palatable? How do you we merge them together and come in the middle and find solutions that are more creative than just, "Here's a great idea. Let's just do this."
Bonica:	Let's talk a little bit about Claremont before we come to talk about your current role. Tell me a little bit about the town. What do you know about the history, the demographics...
Wright:	Claremont's a fantastic city. It's one of the few designated cities in the State of New Hampshire. It celebrate its 250th birthday this past summer. It has a very diverse population. We have international business folks. The North Country Smokehouse here in Claremont sells smoked meats around the world. We have a variety of other businesses that do work and business around the country. Crown Point Cabinetry sells kitchens and cabinets to people who walk the red carpet in Hollywood.
	We also have the other end of the spectrum: some of the most economically disparaged people in the state. Sullivan County is the second most economically disparaged county in the state behind Coos. We have our challenges. There's a decent group of folks in the middle who are what I think we would classify today as the working class. It's very diverse, and that is a blessing in terms of how you work here and how you collaborate. Diversity is always a good thing, and difficult. Difficult as a service provider who needs to be able to serve all those consistencies in a way that's meaningful to each of them. Every time we provide a service, we have to provide it consistently clinically, but more custom tailored to meet the individual's needs.
Bonica:	Hospitals are often a major economic engine for small towns. Coming back to the communities and ecology, how do you, as the CEO of the areas hospital, interact with the business, nonprofit, and government leaders in town?
Wright:	That's a part of my job that I think take perhaps the most seriously. I believe that we're here to serve the community, and it's not just to provide healthcare services. We are part of the economic development engine that needs to happen here. I'm very involved with things that go on in the community college, I'm very involved with the city council, I get involved with business groups and I make myself available 24/7 to the business leaders to help solve their problems. People say, "Why are you going to help businesses solve their problems?"
	It's pretty easy: if I help them solve their problems then they stay and grow and attract more businesses. The more businesses that are here, the more people working in our community have insurance and can get better access to healthcare. Then they become, and the community improves in its wellness and it spirals from there. I take a macro approach to it.
Bonica:	This is a rural community. Hospitals require specialized, skilled employees. How do you find the skilled workers that you need to fill the roles that you have here at the hospital [crosstalk 00:21:57]?
Wright:	That’s a challenge. Some positions it's quite easy to fill, and other it's incredibly difficult. We support, for example, the local schools. River Valley Community College has a great nursing program and we make sure that that program thrives because we'll benefit from it. They just merged with Lebanon College. Lebanon College had a rad tech program. We obviously support that program. We're a huge economic engine. We have 400 employees, we have a $23 million payroll that gets turned over several times in terms of its economic impact in the community. We're not only important to the health of the community, we're important to the economic vitality of the community, which is difficult because the cost of healthcare needs to come down.
	We act as our own educational institution often. My mantra has always been we need to hire the right people. That doesn't necessarily mean they have the skillset that we need. It means they have those infamous soft skills that we talk about all the time, that they understand customer service, that they understand ethical principles and have a high potential for emotional intelligence. If they don't have the technical skill, we can teach them that.
	In my past, I have hired real estate brokers to be physician practice managers. I have hired car salesmen to be functional managers because they understand what needs to be done. You inferred earlier, how can I be the CEO if I'm not a clinician? I don't take care of patients, so, to a certain extent, I don't need to know how to take care of patients. What I need to know is how to support the people who do. Often, that training doesn't come when you go and get a clinical degree like a rad tech, an RN, a physician, a nurse practitioner.
Bonica:	Is the entirety of the Valley Regional Healthcare System nonprofit? Is it a nonprofit entity?
Wright:	Yes and no. Valley Regional is a 501C3 nonprofit entity. Our clinics, our hospital, and our home health and hospice agency are all nonprofit. We are a partner in a company called Summer Crest, which is a for profit independent and assisted living facility that also has a memory care unit in Newport. We own 30%. The corporate structure of that is designed so that the tax liability doesn't fall on the organization itself, it falls back on the members. Our 30% comes non-taxed. The 30% that's owned by a private group of business investors, they're taxed at whatever their tax rate is.
Bonica:	What does it mean for a system or hospital to be a nonprofit? What is a 5013C?
Wright:	A 5013C is a class designated by the Internal Revenue Services that means we're not only non for profit, but we're a charitable organization. People can donate money and claim that as a deduction on their taxes. Nonprofit is pretty easy. We all function in the same way. It's business. At the end of the day, our job is to be as efficient and as profitable as possible. The different in a nonprofit is the margin at the end does not flow through to an owner, investors, or stockholders. It comes either back to the organization for reinvestment in capital equipment or in building a better financial position on our balance sheet, or it goes to reducing the cost of services in the future. The more financially stable we are, the less likely we are to raise our rates.
Bonica:	If there's no shareholders at the end of the day getting dividends back because you're a nonprofit charitable organization, who do you report to?
Wright:	I'm going to take that a little bit further. We don't have stockholders or shareholders, but we do have stakeholders. I practice my craft with the idea that the entire community are our stakeholders. I execute this job by saying they own the hospital. It belongs to the community. Legally, we have a board of overseers, and all you need to do is volunteer and sign your name to a piece of paper and, voila, you're an overseer. You have to participate in a couple of meetings a year that are informative.
	From that group we glean trustees. Trustees are just that: they are entrusted to govern over the organization. They set policy, they make adjustments to the bylaws when needed, and they are chiefly responsible for the quality of the organization. Their other major role is to hire and manage and evaluate the chief executive. I work for a board of trustees which currently is 21 people from our community. I get an evaluation like everybody else at the end of the year and that determines whether I continue in my job or I go looking for something else.
Bonica:	It sounds you're doing a great job in terms of meeting the needs or trying to meet the needs of your stakeholders as well. That's excellent.
	Let's talk a little bit about the organizational structure of Valley Regional Healthcare. Who are your direct reports within the system? Then we'll talk about the hospital specifically, but at the system level.
Wright:	My senior management team, with one exception, has system based responsibilities. Tim Clark is my chief operating officer. He oversees physician practices, non-nursing clinical services and support services. Tim happens to be a registered nurse. Marty Burns is our chief nursing officer. She oversees all of our nursing-specific department: med surg, ICU, emergency department. She also oversees our quality improvement, corporate compliance, and risk departments. Shelly Bragg is our director of human resources. Rolfe Olsen is the director of marketing and community engagement. Jean Shaw is our chief financial officer. Oliver [Herford 00:28:56] is our chief medical officer. Karen [Baranowski 00:29:00] is the executive director of Connecticut Valley Home Care. That's the only person who [crosstalk 00:29:07] home health and hospice.
Bonica:	Let's talk about home health and hospice. What is that organization? What do they do?
Wright:	In short, they're the future of healthcare. In my opinion, keeping people out of a hospital is the future of where we're going. Connecticut Valley Home Care is a home care agency, so oftentimes people will be discharged from a hospital but need continued cared and Home Health is the agency that nurses and LNAs and techs visit you in your home, take your blood pressure, maybe check your sugar levels, talk to you, counsel about diet, exercise. Follow up to make sure that the things that you should be doing you're actually doing to stay out of the hospital or out of the need of a visit to the physician's practice office.
Bonica:	How does that fit into the compensation for the organization?
Wright:	It's a separate billable service. Right now we're still in the what we call the fee for service canoe. Most of the things we do we get paid for. Every time we do a Home Health visit, that's a billable visit. We have a hospice program as well which is taking care of folks near the end of life and making sure that they stay comfortable and that the quality of their life remains high as they near the end. Those are billable visits as well, billable care. Sometimes we have folks who just belong to our Home Maker Program. This is a lower, technical, skilled program. Home Makers don't necessarily have clinical skills, but they help folks go grocery shopping, they help folks clean their house, they help prepare meals. They do whatever they can to help folks stay independent and in their homes.
	We know that the more someone is independent and the more they stay in the home, the longer they'll live, the higher their quality of life, and actually the less that they'll draw down on the health system.
Bonica:	That's the one standalone officer that reports to you. You mentioned your COO overseas, the physician services portion. Is there a physician group? How are the physician services organized?
Wright:	We have what would be best classified as a multi-specialty physician practice group. We have primary care physicians, some medical specialists, and a group of surgeon, most of which are employed by our system. Some of which are on contract. For lack of a better expression, we lease them from the academic facility in the area down at Hitchcock. For example, our urologist, he's here two days a week. While he's here, he's a Dartmouth-Hitchcock physician, so we bring that expertise, but he works for us. We bill for those services instead of Dartmouth. Folks can get the expertise of the academic medical center in the locale of their community hospital and at the building of the community hospital.
Bonica:	Your COO manages this group. How is it separate? How is it integrated?
Wright:	For a long time, they were very separate. They were treated as two different businesses. We used to have separate P&Ls. We treated them like two different companies, and that's really not, what we've learned over time, the best to do that. In addition, there's another designation called provider based which provides enhanced reimbursement in a rural area for critical access hospitals who employ physicians that treats them like a department of the hospital. That's really what we try to do organizationally is say they are a department like radiology, and so they get the same time and attention and focus most of the time. We understand that the pace of the environment in physician practices is different and the way they function is different, so we try not to put a square peg into a round hole. It's complicated. We have lots of regulations and folks who like to tell us how things should be done, and so meeting those expectations and meeting the expectations of the patients can sometimes be a challenge.
Bonica:	Most of your physicians you said are employed by the hospital or leased.
Wright:	Most of them, yeah. It's a weird expression. Most of them are. We still have some private practitioners in the community. We have a dermatology group in the local community who's private practice. We have three or four primary care providers who are in private practice. We support that model any way we can. Just because they're not employed doesn't mean they don't support from us in some way. We are by law allowed to include them, all of our medical staff in our marketing efforts so that when you see an ad that lists all our medical staff, you really won't know who's employed and who's not. It's what services are provided in our community.
Bonica:	The folks who are not employed, what is their relationship to the hospital in terms of ... What privileges do they have in the hospital? What can they do? How do you support them, as you were saying?
Wright:	I'm glad you brought that up and used the term "privileges" because there's a distinct difference between who employs you and who writes your paycheck and having privileges at the hospital. Part of the process that we have here to be a member of the medical staff is you have to be credentialed. Credentialing is a lengthy process that validates your training and experience in previous employment to ensure that you're a quality provider. We need to make sure that the people that we allow to practice medicine in our community and affiliate with our hospital are competent. They apply for privileges, and when they're granted privileges which are ultimately approved by the board of trustees, they are then allowed to order tests, admit patients to the hospital, do surgery, certain procedures. They basically have access. It's a partnership unlike, really, any other business.
	You take a university. The faculty provides a unique service, but they're employed by the university. For us, the medical staff serves in a very similar role as faculty do in that they are somewhat independent, but some of them are employed and some are not. It creates a very interesting dynamic about how the relationship works. For many years it has been the number one difficulty of hospital administration is how to maintain a positive relationship with medical stuff. Oftentimes we're motivated in different ways, we have different things that are important to use, and that can, by the nature of that work, produce tension.
Bonica:	How do you work through those tensions?
Wright:	Like you would in any other environment. You take the opportunity to know your medical staff as individuals, as people, you try to understand what they value, what's important to them. You approach every difficult situation with the first tenet which is I'm fairly certain that this individual didn't come to work trying to ruin my day, that there's something important to them and we're not on the same plain. How do we get to the same level? How do we communicate effectively? I know what's really important to them, they understand what's important to me and the organization, and we approach whatever problem we're trying to solve in a win-win scenario. How do we get to a point where the resolution will be something that they appreciate and can live with and so can we? Like any negotiation, it means you're going to get a little and you're going to give a little.
Bonica:	Looking at the hospital specifically, how is the hospital structured in terms of management structure? You listed a group in your direct reports. If you were going to draw an org chart, what are the big moving parts of the hospital?
Wright:	We're a pretty flat organization in that ... I just told you about my senior management staff. They have managers and directors that either manage a department or multiple departments, and then there's the frontline staff. That's pretty much it. Under the chief financial officer, we have a director of revenue cycle. She manages the billing team, the coding team, and the medical records team. Everything to do with billing and collection. We have a controller who manages our account payable, our payroll, and our budgeting process. We have a materials manager who managers what we buy and where we buy it from and all the contracts that go with that. Those managers and directors report to the CFO, and under those folks are the rank and file staff that get it done every day.
Bonica:	Speaking of the rank and file staff, how many people are employed by the hospital roughly?
Wright:	It changes any given day, but it's about 400, which is about 320 full-time equivalents. FTEs.
Bonica:	It's a big time. How many beds does the hospital have?
Wright:	We're licensed for 25 but we only staff for 21.
Bonica:	What is your average daily census? How many people do you typically have in the hospital at any given time as patients?
Wright:	I think if you look over the course of a year, it's probably around 13. The first 12 days of February, we were full or near full every single day. There has been days when I come to work and we have six patients.
Bonica:	What services do you primarily admit for? What's getting done here in Claremont as opposed to, say, going over to Lebanon to the medical center?
Wright:	We provide the frontline acute, low acuity healthcare. Cellulitis, infections of a variety of sorts, the fly, pneumonia, surgery. We do lots of surgery here. Orthopedic surgery, we do joint replacements, we do knee scopes, we do shoulders, carpel tunnel release. In general surgery we do hernia repair, we do gallstones, we do appendectomy. Those are the basic stuff. We do more complicated surgeries in urology and OB/GYN. Most of the stuff that the average person thinks about that you hear about on the street, if you will, we do. What we don't do is the real heady stuff. Anything to do with the brain, any complicated neurological disorders. We only do the very basic of neurology.
Bonica:	What are the share of the hospital's patients that their payers are Medicare or Medicaid?
Wright:	If you look at any particular service line ... If you looked at primary care or rehab, it might be different, but globally, about 40% of our patients are Medicare, about 12% to 15% are Medicaid, and then the balance ... Another 10% or so are what we call private pay. Those are the three financial classes that we categorize often together because they're the most challenging financially. Medicare at times pays cost often is below cost, Medicaid is substantially below cost, and self-pay often results in bad debt and write-offs probably to the tune of 90% of people who come on a self-pay status don't end up paying the bill.
Bonica:	How does having 50% plus government pay affect the way you organize your services and manage the financial status of the organization?
Wright:	It makes it very challenging. When you have 65% of your consistency whose services are paid for at or below cost, it means that we're operating in a deficit for that service and we need to figure out a way to balance in out. Our hospital isn't really dramatically different than other hospitals in New Hampshire or Vermont. It does fluctuate. There are certain places like in Nashua, St. Joseph's Hospital has hardly any Medicaid whatsoever and very little Medicare. It's a big commercial insurance because the population of Nashua is very heavily 24 to 65 when folks have commercial insurance.
	There are extremes in the state, but it makes it difficult for us, and it means that we rely even more heavily on folks who have commercial insurance to balance that book. It's called cost shift in the political arenas, which basically means the folks with insurance pay a larger price than the folks without. Our financial model has come under attack for many years because of that, and the business community pushes back as they should.
Bonica:	Let's shift gears and talk a little bit about strategic planning and strategic thinking. What is the value proposition for Valley Regional both as the healthcare system and the hospital? What makes it unique?
Wright:	That's a great question. We have six hospitals with 35 miles of Claremont, back in the day it was just proximity. We're the closest. Healthcare has definitely fallen victim to consumerism, which is a good thing, and our customers are becoming ever more discriminating about how they pick those services. As you pointed out earlier, we're not in the business of competing with Dartmouth-Hitchcock. They're an academic medical center and they provide a very high level of service. Our benefit is that we're small. Just the same way the mom and pop store was on the corner where they know who you are and they know what you like and you're treated as an individual and not a number, that's where Valley Regional is really going to excel.
	As I tell new recruits and as I tell our managers when we meet quarterly, we have to give people a reason to choose to come here because they can choose to go with anybody else. Used to be quality. Used to be able to say, "We provide better quality." The reality is quality is really a leveling factor. Everybody is pretty much following best practices and the quality of care is largely, in the upper Valley, on an equal playing field. There's always some adjustment. For us it's about service, and we're focusing on providing really good service and treating people as an individual.
	If you go out in the floor and talk to a patient, they'll tell you that we don't treat patients. We treat our friends and our neighbors and our family and our coworkers. That's the value proposition.
Bonica:	What synergies are accomplished by having a system versus standalone organizations? You talked about an organization where you worked where you took a party system that been in place, or slimmed it down quite a bit. You're currently overseeing a small system. If their synergy's at a smaller level, why not get to be an even bigger system? Why not join up with Dartmouth-Hitchcock, which seems to...
Wright:	We should. Absolutely. There are some that speculate that there will be 20 major healthcare systems in the country in the not too distant future. We talk about, in the upper Valley, banding together to collaborate on services and expand our audience. Right now we consider our service area as Sullivan County, this is a relatively small geographic area, with a broad breadth of service. We need to invert that. We need to look at our service area in a much bigger way, the upper Valley, the western edge of New Hampshire, but narrow our service line. We can't take the shotgun approach of doing everything for everybody anymore. We need to find two or three things that we're going to be very good at and follow best practice and be the best clinically, but also be able to do that at low cost.
	The only way we're going to do that is to partner with all of the six other hospitals in the valley and start forming a system and start specializing. Dartmouth isn't going to do it alone. Dartmouth is talking to UVM and Maine Med and Eastern Maine Medical Center, and they are already collaborating on a few data analysis projects. You can start to see where the potential for a big system for northern New England could very easily come together.
Bonica:	Let's shift a little bit and talk about professional organizations. When did you get involved in the American College of Healthcare Executives? How has that been important to your career?
Wright:	I joined my first hospital in 2001, and so I became a member of ACHE in 2002. I took a couple of their courses, found their education to be really solid, and then was invited to a meeting of a new chapter. In 2003 I think we started the chapter system. I became involved in a chapter and went to the meetings and really embraced the three major elements of ACHE, which are education, networking, and career advancement. I met some folks. I ended up joining a group to study for the Board of Governors Exam to become an ACHE fellow. I got involved in the chapter board, served as the president for two years. Just finish 11 years on the board. I recently also served as the ACHE regent for New Hampshire and spent some time serving at the national level.
	It's a fantastic organization. I can absolutely say without a doubt that I would not be in my position today had it not been for the networking and the mentoring that I got from people within ACHE and the continue exposure to continuing education. For that matter, I met the love of my life through ACHE, so it's a great organization and I my story is, I think, a really good one.
Bonica:	Let's talk a little bit about leadership. One of the things I noticed on your LinkedIn profile is that you have a fairly lengthy discussion about your person vision, your personal mission, and your personal values as an individual. I'd like you to talk about that for a minute. Why did you choose to share those on LinkedIn fairly publicly?
Wright:	That was an exercise I went through in graduate school, to come up with our own vision, mission, and core values. I felt that it was important to do that. It helped me define who I wanted to be and what value system that I was going to subscribe to. I used that in my interviews. I look at the vision and mission and values of the organizations that I interview with and, if we don't match, then I don't progress in the interview.
	At one point I did have the side by side comparison of the organization posted in my office. I don't know where it went. It sets the tone that if you don't match the value of the organization then you shouldn't be here. I think it's something that you need to be incredibly transparent about so that people understand who you are and what you stand for so they know, for lack of a better expression, what they're getting into when they decide to meet you or do business with you. I'm somebody who holds transparency as perhaps the most important value. We're very transparent with our board, our medical staff, our leaders, and the organization about what's going on and why. Putting it out there on LinkedIn makes sure that everybody that I'm connected with holds me accountable to that, and that's a good thing.
Bonica:	I'd never seen it. I thought it was a really interesting thing to do and I like the way you explain how you're using it. Let me ask you about leadership. What do you think makes a good leader? What behaviors or characteristics make a good leader? How do you personally aspire to those behaviors and characteristics?
Wright:	To me, leadership is all about helping people understand that they're more capable of doing things than they believe they are. It's really helping others reach their maximum potential. It's setting that vision and then working with everybody to ensure and make them believe that we can get there. Not get there because I tell them to. There's a difference between me as a manager and what I give directives, "This is what we're going to do, this is what we're going to spend," as a manager.
	As a leader, it's inspiring people to live beyond that potential so that they can do more than what we planned and really reach their own potential within themselves. Which often means helping people recognize that maybe this isn't the right place for them or the right business to be in. I remember distinctly a practice manger I was working with and I said, "What do you want to do?" He said, "I'd like to sometime be a practice director and manager the whole group." I said, "What do you really want to do? What makes you happy? What fuels you inside and makes you smile?" It was a big leap of faith for him at the time, but he said, "I want to be a vet." We reached out to some farmers that I knew and we got him on a farm and he went to vet school and ... It was helping him achieve what was important to him.
	People say, "Why would you do that? You lost a good practice manager?" I said, "I did, but he was only going to be a good practice manager. He was never going to be a great practice manager because he didn't have the passion for it." Leadership is having those honest conversation with people. It's inspiring them and holding them accountable at the same time. It's supporting them and knowing them as an individual, but then pushing them beyond what they're comfortable with so that they can grow.
Bonica:	How do you grow leaders in your organization then? What are your expectations for mentorship within your organization?
Wright:	I always look for people who are creative. There are people looking to advance, and then there are people looking to do great work. You have to treat them differently. People are looking to advance, often you have to put on the brakes and say, "Slow down. It's more important to do what you're doing well than to do it quickly and then get onto the next experience so that you can build your experience so that you can grow." Then there are people who are just in their role and they're very happy to be in their role, but they want to be the best. Those folks I always look to and see what potential they have to grow and take on new adventures. Oftentimes, it's a really fun experience to watch somebody and to give them new tasks and new challenge and have them work out of the box and take risks on them, and then watch them grow.
	The leader that worked for me at Littleton who ended up taking part of my job after I left was a can do all the time, absolutely, we can get that done. He would work late and try to resolve problems and was always very good about, "I can't resolve the problem. I need help." That's how I knew he was always going to go far is he knew what his limitations were, he wasn't afraid to ask for help, but he wasn't afraid to take risks and he was a good communicator. His staff was always upbeat and happy. It didn't mean they liked everything. There were certainly things that they objected to, but because of his leadership and his potential, he helped grow people and he kept them well informed. There was no doubt in my mind when I left that he was going to advance and take over a big part of what I was doing, and he's doing great.
Bonica:	Is that an important part of being an effective leader is being able to grow people? Is that something you're looking for? [crosstalk 00:56:37].
Wright:	I don't think for every leader, no.
Bonica:	You're a leader of leaders. Your direct reports are not the frontline people.
Wright:	Right. Often that's harder because you're ... A good leader, I think, needs to be able to understand and accept and work with people who are smarter than they are and grow them and provide opportunity for then to grow perhaps beyond you. That's difficult to do sometimes. Every human being has got an ego of some sort. It might be a small, tamed one, but it's there. I very firmly believe that you just look for people that have potential and you help them with your experiences and let them grow on their own. It's not a formula that you follow that, "This is what I did." It's always about asking questions and provoking thought and, whatever direction they're going, making them stop and at least look in the other direction. They might be doing the right thing and going in the right way, but they'll never know that if they don't evaluate the whole spectrum.
	I tell people, "If you're doing everything right, then you're not learning." You learn by making mistakes. There's a great story that I like to tell about a gentleman who was working in a business and made a monumental mistake, cost a company $1 million, and he was a pretty smart guy. Goes back to his obvious and starts packing things up. The CEO walks by and sees him packing his boxes and he says, "What are you doing?" He says, "I'm not stupid. I just cost this company $1 million bucks. I'm not going to make big fuss. I'm going to pack up my stuff and I'm going to leave." The CEO says, "Over my dead body. I just $1 million on your education." It's a good point because that individual is never, ever going to make that mistake again, and probably everybody who worked for that company at that time will never make that mistake in their career. '
	I teach snowboarding on the weekends and I tell my kids, "If you're not falling then you're not learning." You have to learn how to fall and you have to learn how to get up. You have to learn what it feels like just before you fall so that when you recognize that you can make a move in the future to avoid it. If you don't fall to begin with, you'll never be great.
Bonica:	You've mentioned that you had several mentors, particularly the person who hired you to be COO. Do you have mentors now? Do you have people you call on to say, "I'm thinking about this," or, "I'm trying to puzzle for this issue," or, "What should I do next?"
Wright:	All the time. In healthcare and outside of healthcare. Mr. West, who was the CEO I worked with for 12 years, he threw my resume away at first, and it wasn't until my good friend reached in the garbage and pulled it out and put it on the table and said, "Just interview him." I remind him of that every year on the anniversary that he hired me. The one thing that I'm always surprised about in this position is how lonely it is. It is a very lonely position. Unless you've done it, you can't really truly understand it. I thought, as a COO, that I knew exactly what it was going to be about and that I could do it. What I didn't realize is all of the confidence I had in the way I executed my job as COO was backed up by the safety of a good CEO, that he provided a safe environment for me, and so I felt confident.
	When the buck stops at your desk and you have 21 bosses who their objective is to do right by the community, and so the moment they cease to find value in you as their chief executive, you're gone. ACHE does a study every year; CEO turnover is about 20%. One in five CEOs will not be in their position next year. If you think of that globally, it means that they only stay in their position for five years. At five years you're just hitting your stride.
	Warren, who has been a mentor of mine for the better part of 14 years. A wonderful CEO and founder of a company called [Strategies 01:01:17], his name is Neil [Dukoff 01:01:18], who I have known since I was nine years old, and largely taught me everything I know about general business. I call him on a regular basis. My peers in the state at other critical access hospitals, sometimes I call up and I, "What the heck do you do with this?" I'm still new in my tenure, I've only been a CEO for two years.
Bonica:	That means you have three more to go before you go.
Wright:	Correct. Don't think I don't think about that every day. I'm the youngest CEO in northern New England as best as I can keep track, which means that I need lots of advice. I'm very fortunate that I get to travel in my job and meet lots of different people in the healthcare industry and outside the healthcare industry. I take every relationship and hold it precious. Everybody's got a valuable insight, and what I've come to conclude is that it's not one person's opinion that helps me do my job, it's the culmination of everybody's opinion that really helps solidify when I need some support.
Bonica:	Do you have relationships with junior executives outside of this organization? Other hospitals? People that call you as a mentor?
Wright:	Yeah, absolutely. Some of them have more experience than I do. I think the way that I got into this business is so untraditional that it is attractive to people to seek me out. I don't mind taking unpopular positions. I think I'm building a slight reputation for being a functional disruptor. Oftentimes at the hospital association we'll look at how to resolve a problem, and then everybody's who's been in this business for 20 years comes about it in the same way and I'm the disruptive person in the back going, "Isn't the definition of 'crazy' doing the same thing and expecting a different outcome? Why don't we take a different approach?" Lots of times I hold onto my non-healthcare experience and draw down on that knowledge and say, "Maybe we should do it a different way." Often it doesn't result in us doing it that way, but what it does do is provoke the thought to come up with a better solution.
	Some of my peers will call me up and, "What do you think?" Like any group of like-minded folks, there are smaller groups ... There's probably a group of five CEOs in New Hampshire that we change emails or phone calls on a regular ... "How do you do this?" I'm connect in probably three or four different of those micro groups. Those are the people that I reach out to when I need help?
Bonica:	Let's close on this question then. What advice do you have for people who are just starting a career in healthcare administration? What should they be doing to be successful? What should they be reading, maybe listening to other than, of course, Health Leader Forge? Who they should be talking to? What organizations should they belong to?
Wright:	A couple of tenets that I have; I think it's incumbent upon all healthcare leaders to give back to your profession. Join a professional organization. I personally will tell you that ACHE is the premier professional society in healthcare. They're well-known for that. It's crazy not to join. It's relatively affordable, the education is amazing, and you will meet people and gain experiences that you just can't quantify.
	I think equally that we need to give back to our community. Whether that's your time, money, or both, it doesn't matter. If it's a church group, a school board, a rotary club, whatever it is, you need to give back to the community substantially. Not just I donate to this effort every year. You need to be seen and you need to advocate and you need to educate in the community about what it is to be a healthcare professional.
	For young executives and senior executives alike, volunteer for everything. Someone coming out of school, they have a limited amount of experience. The only way that you're going to get more experience is to just do it. Volunteer for every assignment, committee, project, anything that you can. You need to have a clear path. What do you want to do? Do you want to be in operations? You want to be in planning? Do you want to be in quality? You want to be a clinician? Figure that out, and then volunteer for as much as you can in that direction. Never be afraid to stop and say, "I guess I really don't want that. Maybe I'll go in a different direction." Volunteer like crazy. Don't ask for the money upfront. Volunteer, show that you can do it, and then once you do it competently, the money, the promotion, the other opportunities will come.
	Many young executives focus on the money part and say, "I'll do this, but you got to pay me." That's really the wrong attitude because there's probably someone else who can do it better for the same or less money. That was the secret that I had. I was annoying. I volunteered for everything. The first physician practice that I ever managed, my boss told me no. I had no experience managing physician practices and he wasn't going to give it to me, and so I pestered him. Then I started talking to the physicians and I made it their idea. They went and told the CEO and, presto, I got the job. I didn't take an extra cent for it because I didn't know what the hell I was doing, and so, if I failed, then I could just step back and wouldn't have to be worried about what they invested in me outside of time.
	By just volunteering to do it, once I proved I could do it then it became a lock, then I got the money and the title, and the next growth opportunity came. You have to volunteer. I think the last thing is go to work and never forget that everybody in your organization came to work with the same idea: to do a good job and to help people. You take that adage of don't judge until you've walked a mile in their shoes. If you're having trouble with an associate of your or another department, assume that they're not trying to be difficult, that there's something going on in their life or their department and try to understand what that is before you judge and say, "They're lazy. They're incompetent. I'm not important to them." 98 times out of 100 you'll find that they really do have the best of intentions and something you didn't know about was going on.
	You'll go a long way and people will seek you out as an ally when you hand out that olive branch first and you take the time to understand how difficult their life is instead of trying to make them understand how difficult yours is.
Bonica:	Good advice. Thank you for the interview today. Thank you for being part of the Health Leader Forge community.
Wright:	Thank you very much for the opportunity. It was a great pleasure.