The power of teamwork

Dr. Eileen Bridges: Welcome everybody to the CMPA Webinar Series.

Now, before we begin, we would like to acknowledge that the CMPA offices, that are located in Ottawa, are on the unceded, unsurrendered territory of the Anishinaabe Algonquin Nation, whose presence here reaches back to time immemorial. We honor and pay our respect to these lands to all First Nations, Inuit and Métis Peoples throughout Turtle Island.

Healthcare professionals all agree on the importance of effective communication among members of the healthcare team. And the CMPA's Power of Teamwork webinar is designed to address challenges associated with effective, inter-professional communication.

Now, throughout this program, physicians will learn strategies to promote psychological safety and improve their inter-professional communication skills to achieve a workplace culture that values respect and collegiality.

I'm Eileen Bridges and I'm a senior physician advisor here at the CMPA.

Dr. Cheryl Hunchak: And I'm Cheryl Hunchak. And I'm physician advisor here at the CMPA as well.

We're both paid employees of the CMPA, and otherwise we don't have any disclosures to make.

And these are some of the steps that we, as an organization, take to mitigate any potential bias.

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Mitigating Potential Bias:

• The Scientific Planning Committee (SPC) is comprised of Physician Advisors who are employees of the CMPA; its composition is common for all the CMPA's Practice Improvement workshops or courses.
• The SPC has a process in place to manage identified conflicts of interests:
  • All SPC members have completed and signed conflict of interest (COI) disclosure forms.
  • The SPC has reviewed all COI forms and indicated that none of the relationships disclosed pose a potential conflict of interest.
• The SPC was involved in the planning and development of the content of this program to ensure that the educational activity is evidence-based and has scientific validity, integrity, objectivity.
• The CMPA is a not-for-profit organization and this CPD activity has been developed without external support.

Eileen: So, here's our learning objectives for today.

First of all, we want to examine behaviours that encourage psychological safety in teams. Then, describe how psychological safety in teams improves patient safety. And finally commit to one simple strategy leading to positive change on your team.

Cheryl: So, what we hear from physicians is that delivering care was already difficult before the pandemic, and now, we all face even greater challenges. Regardless of specialty or the region of the country, more and more of our members are telling us how difficult they're finding it to take care of their patients in the way that they would like to. Many are finding it actually an impossible and thankless task.

Eileen: It's right. On the other hand, though, we have also heard that despite the constraints and obstacles that we face as physicians, it's still incredibly rewarding to have a positive impact on our patients' lives.

So, today, we're going to explain how the positive human interactions we have in our professional life are not only rewarding, but also influence the way that we learn and adapt to complex changes and challenge.

Cheryl: So, to frame our conversation, Let's talk about a case.

Mr. Gus is an 82-year-old widowed male and he lives alone. He's followed by his family physician for type 2 diabetes, hypertension and depression. He also sees a cardiologist annually, as he has a history of coronary artery disease, and a physiotherapist for a shoulder issue that he has. There's also a social worker involved with him, as well, and they coordinate some home services to help him out.

So, one day, Gus phones his family physician and he describes that he's having new symptoms that are bothering him. His family physician is worried and advises him to go to the emergency department for assessment.

Now, Mr. Gus is actually quite hesitant to go because he knows that going to the emergency department may mean waiting for a long time in a crowded, uncomfortable space.

Eileen: And, probably not wrong, right? So...

Cheryl: Yeah.

Eileen: A few days later, a neighbour finds him collapsed on the floor at home and calls 911. He's taken to the emergency department where he spends the next 48 hours. He's seen by a rotating team of emergency doctors, other physicians, nurses and trainees.

He's also seen in consultation by various members at different levels of training of a number of other hospital services, including internal medicine, family medicine, cardiology, geriatrics, neurology and social work.

And, at the end of the 48 hours in the emergency department, it remains undecided whether it's safe for him to return home, nor is it clear that he requires an admission to an acute care facility.

No doubt, this case will resonate with many of our members, Cheryl.

Cheryl: Oh yes, and us too.

Eileen: Yeah.

Cheryl: We've shown just a few factors here, but it really doesn't take long to realize that there are more than we can actually count.

No one person is responsible for what prevents Mr. Gus' health needs from being met because several factors explain this clinical situation.

And, as we know, this frequent occurrence is frustrating for most of us involved because, despite best efforts, the healthcare system somehow seems unable to meet the patient's needs.

Eileen: Right.

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List of interconnected factors: Healthcare funding; Social expectations; Community and Hospital siloed from each other; Siloed hospital departments; Siloed community practitioners; Pandemic; Constraints on physician; Overcrowded ED; Professional regulation; Patient’s social network; Community resources; Patient autonomy, values, financial independence; Alternate level of care space, suitability, appeal

Cheryl: There's a complex web of interconnected factors. They all exist for a reason but they interfere with our ability to provide the kind of holistic healthcare that we would like to, the care the patients need to reach their best state of health.

Content of on-screen slide, representing four interconnected factors under the title “Seeing the big picture”

• Hospitalist role to improve efficiencies in inpatient care
• Decreased length of stay and in-hospital costs
• Increased Medicare costs, ED visits and readmissions
• Overcrowded ED

Eileen: And what's more, focusing efforts on only one or a few of these issues, without understanding the bigger picture, can sometimes lead to unintended consequences.

So, let's take an example here.

There was an American nationwide observational study that was published in 2011. They looked at creating hospital-centred efficiencies to reduce costs and lengths of stay. And that's exactly what they found. What was unexpected, however, was that in the thirty days post-discharge, implementing these efficiencies was associated with increased overall costs, emergency department visits, and readmission rates, which more than offset the hospital cost savings.

So, in fact, they found that the introduction of certain hospital-centred efficiencies had the opposite of the intended effect.

Now, what I learned from this is there is so much more to the story than meets the eye, which is why a holistic approach based on collaboration between teams is so important.

Cheryl: So, here's where relationships actually come in. We've just showed you an everyday case and we identified that there are many deeply interconnected factors that determine what happens next. If we try and fix individual factors without sufficient understanding of those interconnections, we may be disappointed with the outcomes.

Eileen: So, and as you heard in the first webinar that we did, Cheryl, optimizing interactions with our patients, we can achieve better outcomes when we have conversations that matter, conversations that allow us to explore new ideas, challenge old assumptions, try things out, and to learn and innovate.

But these conversations that really matter can only happen when people feel safe enough to share what's really on their mind, without fearing that they're gonna have to pay a price for it, right? And that safety depends on healthy and respectful relationships.

So, let's demonstrate what we mean by that, and talk about another US hospital system that was facing an unsustainable rise in liability costs.

Now, this network was faced with the possibility of being unable to cover their operating costs, because of a growing number of expensive lawsuits.

So, there wasn't a clearly understood single reason for the lawsuits, and consequently there wasn't an obvious solution either.

Now, there was evidently major quality and safety problems, and the environment wasn't great, but it wasn't sure which was the chicken and which was the egg in this situation.

So, in order to address their wicked problem...

Cheryl: I'm sorry, Eileen, I actually don't know what that means. Can you tell everybody what you mean by wicked problem?

Eileen: Sure, Cheryl. A wicked problem is a problem that's difficult to solve because of incomplete, contradictory and changing requirements that are often really difficult to recognize.

So, the bottom line, it refers to an idea or a problem with no single solution. Right, so, in order to address this wicked problem, the hospital network implemented a multi-pronged approach to medico-legal risk reduction.

And that included a risk-reduction initiative program to improve quality and safety in their hospitals. Every clinical department – in-patient, out-patient, primary care, specialists – they were all part of the program and they were tasked with making things better.

Cheryl: Good, general start! I wonder how that was receive.

Eileen: I'm not sure. But what was really interesting was how they actually went about doing it.

So rather than telling the clinical leads what changes to make or how to make them, the hospital did something different. They allowed new practices to emerge by establishing clinical communities.

These were horizontal communication channels. And they were between frontline clinicians who might not otherwise know that they were facing similar challenges.

They created a space where it was safe for physicians to engage with colleagues and tap into their collective creativity.

And the results were really nothing short of transformative.

Cheryl: Wow!

Eileen: A number of themes emerged from these grassroot conversations, including ideas to reduce variability around high-risk practices, improve workflows, and enhance their patient experiences.

Some were... I'll give you a few examples, here. Some of the examples of projects that came out of this were difficult airway simulations outside of the OR, a patient safety climate survey implemented in the obstetrics department, and a system-wide training in disclosure of safety incidents.

Changes were also made system-wide to the reporting and following... follow-up of laboratory results. And what's more, seven years after initiating their project, 86 percent of all these projects were either successful or ongoing.

Cheryl: Wow! So, OK, so from what I understand, the hospital leadership didn't really have a clear idea as to what the outcomes were going to be when they started the program, but they ended up seeing the change that they were really looking for.

Eileen: Yeah. Multiple quality-improvement initiatives were implemented, patient experience improved and malpractice costs in that particular hospital system were cut in half at the 7-year mark.

And as far as we know from a CMPA study, there's a really strong relationship between patient safety outcomes, that's represented here, on the X axis, as PSI events, and medico-legal cases, represented here on the Y axis.

And this suggests that reduced medico-legal liability could be a secondary benefit of improved patient safety.

Content of on-screen slide, representing a graph titled “Patient safety outcomes and medico-legal risk”, where the X axis is titled “Change ratio, PSI event” and has values going from 0.8 to 1.2, and where the Y axis is titled “Change ratio, medico-legal case” and has values going from 0.7 to 1.3

Cheryl: So, these were really impressive results, Eileen. It's an inspiring story and it's also a bit overwhelming too, I must admit, because most of us don't work in a big centre like this one or necessarily have the resources that the clinicians involved in this risk reduction initiative clearly had access to.

Eileen: Yeah. And, so, thanks for bringing that up. I think what's really important to focus on here is what it was about the clinical communities that they established that led to these changes. Because we know that simply telling people to talk to one another doesn't guarantee innovation.

Cheryl: Yeah, you're absolutely right. And the key to this program is the environment that they established. That's what led to their success. And that, we can actually reproduce anywhere. Whether we work in a really large organization or a smaller clinic, the answer is the same.

Eileen: The people at this hospital network were able to create conditions where it was not only permissible to challenge one another's thinking, it was actually expected and invited. They didn't need to agree on what to do, they only needed to agree on a need for change. And it was probably uncomfortable to have the initial conversations they had, but the vulnerability the clinicians showed in having them was rewarded in time.

In other words, the physicians felt safe to share ideas, try them out, and ultimately to benefit from them. And, by creating an environment where it felt safe to talk to one another, where the organization and people within it had the humility to acknowledge that there may be a better way to do things, a philosophy and culture of quality improvement was established.

And what's important at the outside... outset is the desire to change and improve. And then, do it in an environment that supports these important conversations.

So, small changes really work well as a start. And then, you can build the momentum and the culture, right, that's necessary for successful change over time.

Now, this is not a unique example. As the problems we face become increasingly complex, high-performing organizations realize that sustainable changes are much more likely to occur when collective creativity is mobilized, rather than relying on one single person's brilliant idea or force of will.

Cheryl: For sure. And speaking of performing organizations, Eileen, let's just step away from healthcare for a second and let's talk about Google.

So, I'll preface this by saying, first and foremost, that we're well aware that the environment in Google does not directly compare to the healthcare environment.

I'm bringing Google up though because, in 2012, they undertook a multi-year project that they called Project Aristotle. And this examined why some of their teams thrived, and why others failed.

It's the outcomes of this project that are actually quite relevant to our work in healthcare.

So, as part of this project, Google identified five essential qualities for building successful teams. The first of these was dependability, meaning whether the team could count on each other to do high quality work on time.

The second was meaning of work or the feeling that the team was working on something that was personally important to each of them.

Thirdly was role structure and clarity, meaning whether the goals, roles and execution plan on the team were clear.

And the fourth was psychological safety. This refers to whether the team felt they could take risks without feeling insecure or embarrassed.

When we ask physicians which of these attributes they think Google found was the most important to building a successful team, most really figured it out.

So, Google studied 180 different teams around the world and found that psychological safety was in fact the single most important factor impacting team effectiveness.

So, being dependable, having structure and clarity, finding meaning in our work, and seeing the positive impact of the work, these actually really depend on the individual...

Eileen: Right.

Cheryl: …whereas psychological safety, on the other hand, cannot exist without the whole team. And, it is this quality that truly depends on how the team functions, especially among healthcare teams.

Eileen: Absolutely, Cheryl, let's talk a little bit more about this because this definitely applies to healthcare, where we almost always work within teams of various sizes and composition.

A psychologically safe environment is one where people really listen to one another, right? And feel safe to speak up without feeling afraid that they're gonna be punished or embarrassed.

Cheryl: That's right, and it's also not just about harmony or being nice to one another. In fact, people don't really actually need to like each other, as long as they respect each other enough to listen and recognize each other's viewpoints as valid.

It's not about comfort, either. Learning new things or challenging old ways of thinking is almost always, by definition, uncomfortable. Psychological safety means being able to be comfortable with that discomfort.

It's also not about democracy. Not everyone needs to get a vote on a given decision, but it is the case that everyone needs to feel heard.

And finally, it's not about consensus, either. So, at the end of the day, everyone must still respectfully disagree, and when they do, that is actually accepted.

Eileen: Right. So, one further thing that's important to appreciate is that psychological safety is not stable. It only takes one unintention... only one remark to undermine it completely, right?

Content of on-screen slide, representing a house of cards under the title “The relationship between patient safety and psychological safety”, where “PATIENT SAFETY” is at the top level of that house of cards, followed by “Situational awareness” on the second level from the top and “Team communication” on the third level, and where “PSYCHOLOGICAL SAFETY” is at the base of the house.

Dr. Hunchak: Yeah, in the healthcare system, high psychological safety in teams has been linked to creative performance and knowledge sharing, technical team performance, quality improvement, and patient-centred care.

Dr. Bridges: So, we've talked a lot about psychological safety. Where does it come from? How do you build it, right?

So, let's give an example of a physician who takes deliberate action to build psychological safety on his team. And just so you know, this is not fiction, this actually does happen, and it works.

So, as you watch this video, think about how this physician created a psychologically safe space and is encouraging speaking up on his team. Let's take a look.

Embedded video transcript: ...Terry. I like to go by Terry, as you know.

And the way all of you can... can make me safer.

I'll be the attending on the team today.

The way you can all make me safer is... tell me if you think that I or anyone else on the team is making a mistake. And even if you're wrong, I'll be nice about it and I'll really appreciate the fact that you've brought it up, because I think as a team we can be safer together.

So... Jamie!

Hi! I'm Jamie. I'll be your TL today. The way you can make me feel safer, us be safer, is if you can verbally communicate, as well as just not putting things in the computer, so that we know that we're all talking about the same patients at the same time.

I'm Katie, resident, and it would be great if there's any abnormal vital signs, or any changes in vital signs, if you'll make sure that you guys point that out to me, just to make sure that we're aware.

Cheryl: That certainly is a team environment that I would feel comfortable practicing in or working in. And you know, honestly, it's not deliberate phrases that we're necessarily hearing on our teams everyday.

Eileen: No, you're right.

Cheryl: Ok, so let's tuck into this then, what actions can we take or have you seen others take in our work environment that promote psychological safety?

Eileen: Great question, Cheryl. Let's talk about some simple ways that we can grow psychological safety in our own environment.

Now, there's a group in the US called LeaderFactor, and they evaluate psychological safety in organizations. And they categorize psychological safety into four levels that can be achieved sequentially.

The levels start with inclusion, then learning, contribution and, finally, challenging safety. And as you go up in the levels, the need for an environment that offers respect and permission increases.

Cheryl: So, let's spend a few minutes now explaining what each of those levels are actually about, because for each level, there are some simple tools that we, as physicians, can adopt to build psychological safety in our environments.

The first level, which is called inclusion safety, means that everyone feels like they belong. Team members feel safe to be themselves and are accepted for who they are. This is how we begin to build a foundation of trust.

Inclusion safety isn't earned, it's owed. Everybody deserves it, that means letting go of our biases, conscious, and being aware of our unconscious biases, our preconceived opinions and judgments.

Eileen: So, the second level, learning safety, you know, this means that team members feel safe to ask questions, receive feedback, try things out, and even make mistakes.

Cheryl: As we start to feel comfortable with the first two levels, we can then reach contribution safety. Contribution safety allows people to feel safe using the skills and abilities they gained to contribute to the collective vision.

Eileen: And finally, challenging safety. This is where people can leave their comfort zone and trust that they can speak up respectfully when they see an opportunity to improve the way things are done without any fear of retribution. And this is a vulnerable place, but this is where innovation and creativity actually happen.

Cheryl: Absolutely. So let's break these down, Eileen, and let's talk about simple strategies within each of them that we can follow to build psychological safety.

Eileen: Right. Sounds great. Let's start with inclusion, the first level of psychological safety.

Cheryl: So, inclusion behaviours take no time at all, yet help to build that trust foundation. Think about when you walk into a room, how do you know that you feel welcome? You know? So, actions just quite as simple as people introducing themselves, learning people's names and how to pronounce them, these are easy ways to feel welcomed and to show warmth.

Eileen: Sounds so simple, eh?

Cheryl: It's so simple and in our busy environments it is well worth being mindful of these, yeah. Even when people face us and look at us when we speak, even when they're busy, this conveys that they truly care about the interaction.

Eileen: Yeah.

Cheryl: And asking more then we talk means listening with an intent to absorb what people are saying, rather than with an intent to respond. I think this is a big one in, again, busy healthcare environments. This demonstrates engagement, respect, and curiosity.

Eileen: Right.

Cheryl: We're all responsible for being mindful of our own behaviours, especially those that may unintentionally undermine psychological safety for others.

And, finally, frequent touchpoints. Even when very brief, these can help build team connections. So, instead of telling your learners, or perhaps your team members "Oh, just call me if you need me!", you could instead tell them that you plan to check in on them frequent... not "on them", but check in "with them" frequently to see if they have any questions or concerns throughout the day.

Eileen: Right. So simple, Cheryl, as we said, but... So, not always easy, are they? Particularly when we're required to work with people whom we may already have a past history, right? Or with people that we may disagree with on certain issues.

So, it can feel like there may be a divide that makes it harder to work together, but these behaviours that foster inclusivity help demonstrate our own willingness to engage and find common ground.

And again, it's possible to disagree on certain issues and still feel psychologically safe to express our ideas and our viewpoints, keeping in mind our patients' best interest.

Cheryl: So, let's move on to the second level now: learning safety. How do we make others feel safe and motivated to learn?

One technique that I find particularly powerful is when team leaders share what they learn with their teams. So, I find that when leaders share with other people their own excitement about learning something new, it really encourages everyone else to adopt that learner mindset and to learn as well.

Eileen: Right.

Cheryl: And it really drives the point home that everyone is, in fact, always learning and that no one is expected to know everything, and also that everyone should feel safe to be curious and to learn.

Eileen: So, another one that I like, Cheryl, is celebrating the learning opportunities when things don’t go as intended, right?

There's a lot that we can learn from failure, as well as our successes. And then, communicating what we learned when things don't go as intended not only improves patient safety moving forward but it destigmatizes failure and makes it more likely to be surfaced and discussed.

And then, we... you know, that, in turn, can lead to improvements in the way that we do things in our environments.

Cheryl: That one, for sure, is not easy, though. I think we can all agree on that. You really need to be feeling safe to be able to come forward and talk about when things haven't gone as intended. And this is again why building trust between team members at that foundational level is so important.

Eileen: Yeah. OK. Let's move on now to contribution safety. We'll start with a simple statement: Celebrating small wins empowers people, Cheryl. True or false?

Cheryl: That one is true, definitely! Accomplishments and wins increase confidence, and build momentum, even if they're small. And recognizing these small successes energizes people, and it gives them fuel to keep going.

Eileen: Right.

Cheryl: When we recognize other people's accomplishments, they take pride in what they do and find meaning in their work.

Eileen: Alright! So, another tool that we can use, when we get to the contribution level of psychological safety, is giving some people stretch assignments, right?

Pushing people out of their comfort zone just a little bit, but not so much that they're out of their depth, right? Just enough so that they grow and are excited about the new responsibilities that they have.

But in order to do that, those first two levels of psychological safety need to be clearly established, so that people feel safe with their discomfort that comes from stepping out of that comfort zone.

And then, it's extremely helpful to remind people of the meaning of the work that they're contributing to, and the impact of what they do. It helps establish a common vision so everyone on the team knows where they're going and that they're all contributing to something impactful.

So now, we're in the final stage of psychological safety: The Challenge your safety level.

This is where people have the confidence to speak their mind when they think that something needs to change, without fearing negative consequences of speaking up.

It's by far the hardest level to achieve but also the most rewarding one, because this is where the innovation is likely to happen.

Just like we saw in the example of the American hospital that improved the quality of care delivery.

Cheryl: One way to invite people to challenge the status quo is actually to assign dissent. So, this may seem counterintuitive, but if we explicitly assign members of our team to challenge a particular course of action, we remove some of that individual's personal risk by giving them explicit permission to challenge constructively.

Eileen: Constructively, yeah.

Cheryl: Let junior members, and in fact all members, know that they're just as welcome to challenge ideas as any other members on the team.

And encourage everyone to come to the table with openness, humility, and a willingness to be wrong sometimes. Recognize team members with enthusiasm when they challenge that status quo. Many ideas and suggestions will not necessarily meet the threshold for implementation, but if we encourage the attempts, the overall creativity of the teams will increase.

Eileen: Yeah.

Cheryl: If and when disagreements arise, finding common ground can be a very helpful strategy to keep your team on track. The collective team vision, and acting in the best interest of patients, is common ground that can foster a more effective team workplace, and a safe and positive experience for your patients and for your team as well.

It's important to remember that even if we start doing all these things today, psychological safety in our environment may not improve immediately. Nor may it guarantee a specific result. But just like sticking to an exercise program, and we all know that that can be certainly very challenging, practicing these simple rules, returning to these simple rules over time and doing just a bit everyday, over and over again, will definitely result in a positive change, again over time, and no one can say exactly what that change will look like, but as we saw in our case examples, the potential is truly there for it to be transformative.

Eileen: OK, so, let's go back to Mr. Gus, our patient, and recall the complexities of his healthcare needs, and the complex healthcare system that is trying to support him. At the 48-hour mark in the emergency department, Mr. Gus and his healthcare team are no doubt wondering: Is there a better way?

Cheryl: Yeah. These are complex problems without easy answers, I think we all know that, Eileen. And finding solutions begins with building teams that can adapt and thrive. This is how we will adapt and thrive over time.

Eileen: Right.

Cheryl: We need to build and to practice the foundational ingredients for effective teamwork, which starts with the steps that we've outlined to build psychological safety.

As our population ages, like Mr. Gus' case gives an excellent example of, we must adapt in order to thrive. And to be able to adapt in productive ways, we need to be able to think about how our systems and also how ourselves, as individuals, can foster this.

Remember that study, where the health network allowed new practices to emerge by establishing those horizontal communication channels between the frontline clinicians. And, remember, those were clinicians who might not otherwise have been aware of each other's challenges. They deliberately created a space where it was safe for physicians to engage with their colleagues and tap into their collective creativity. And you'll recall that those results were transformative.

You'll also recall that it, in fact, took several years of incremental work to see those results, not weeks or not months. System change definitely takes time, but building psychological safety within your current team, starting today, will yield more immediate results. These small wins will feel palpable, and will help the individuals on your team thrive, and ultimately lead to those bigger wins.

Effective teamwork really begins with each of us and has the power to transform our work lives, our systems, and the care we provide for our patients. Effective teamwork allows us to provide the care we want to provide for our patients, and in this scenario, everyone thrives.

Eileen: Absolutely right, Cheryl, so let's… let's just review the key take-away messages that we have to start intentionally building psychological safety in our teams.

The first take-home message is that effective teamwork starts with psychological safety. For each individual and team, it may be the case that some elements of what we've discussed today are already in place. And you can strengthen your team with some of the ideas presented here today.

Others may need to start from scratch and set a new culture for psychological safety. For teams that are functioning effectively, perhaps some of the systems change ideas will help begin to innovate solutions for your particular challenges.

Cheryl: Exactly! And psychological safety can be fostered by explicitly encouraging others to speak up, to listen more than tell when they do, and to build frequent touchpoints into teamwork.

And finally, some strategies for improving inter-professional communication include adopting a learner mindset in a deliberate way, and being genuinely curious about the perspectives and ideas of others on your team.

Finding common ground can help strengthen relationships within all of our teams. And collectively agreeing on a common team vision. So, for instance, something as foundational as everybody agreeing that we're all here to keep patients safe. This can promote team cohesion and help manage disagreements.

Finally, learning from successes and failures, and really celebrating these learnings, whether success or failure, helps teams move incrementally forward. What this means for each team will vary. But learning from mistakes and feeling safe to talk about them is something we can certainly improve upon and, ultimately, benefits us as individuals, as teams and, of course, benefits our patients.

Eileen: Thank you, Cheryl.

Now, we would be remiss not to thank all of our members for the incredible work that they do on a day-to-day basis. And this is in the face of those challenges our healthcare system has had to meet over the past few years.

Despite this, you've shown up everyday for your patients. And, in an environment that keeps changing and challenging us, it's so important for all of us to continue to see and to acknowledge this to each other.

So, thank you everybody for the work that you do.

If you have any questions regarding a specific situation, we invite you to call one of our CMPA physician-advisors, so they can work through the details of the situation with you.