Luke McGuinness has served as a chief executive officer in health care for over 30 years. He joined Central DuPage Health (CDH) as president and chief executive officer in July 2003. Since that time CDH has undergone a physical and intellectual renaissance, which has included recognition as one of America’s Top 100 Hospitals by Thomson Reuters for four years in a row, and the conception and execution of over $1 billion of capital projects.
From February 2000 to June 2003, he worked for Vanguard Health Systems, Nashville, Tennessee, serving most recently as senior vice president for development. Prior to that, he was the president and chief executive officer of MacNeal Health Network in Berwyn, Illinois.
Mr. McGuinness also serves as chairman of the board of The Arthur Foundation and has held numerous elected positions in professional associations. He received his bachelor’s degree in finance from the University of Notre Dame and a master’s in business administration from George Washington University.
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This Conversation took place in McGuinness’ office at Central DuPage Health, in Winfield, Illinois, on Thursday, November 11, 2010. Participating were Luke McGuinness, Liz Rosenberg (CDH vice president), and Al Erisman. Liz Rosenberg contributed briefly to the Conversation in several places, and her comments are indicated with her initials.
Albert Erisman: As I have been exploring the health care field, I have found that some hospital CEOs are also physicians and some are professional administrators. How did you get into hospital administration?
While matriculating in graduate school, I had the good fortune to meet Sister Gertrude Bastnagel, who went on to become the provincial for the Daughters of Charity, which at the time owned and operated the biggest hospital system in America. After following her in a residency, I was asked by her to serve as associate administrator for her in Southfield, Michigan. Not only did she give me this opportunity, but because of their national presence, I also got to participate in and observe many developments in the country.
In 1979, I was named chief executive officer of MacNeal Hospital, in a suburb of Chicago and worked there for 21 years. During that period, the hospital renewed itself both intellectually and physically. Intellectually, we recruited an entirely new medical staff and management team and physically, we built a new hospital and turned it into one of America’s 100 top hospitals. In 2000, the hospital was sold to Vanguard Health System, a for-profit start-up hospital company and for the next three years I worked for them as senior vice president for development. This experience offered me an opportunity to see how a for-profit hospital operated versus not-for-profit.
After three years, for personal reasons (too much travel), I resigned my position at Vanguard Health System. I became CEO of Central DuPage Hospital in July 2003. Before I joined CDH, the hospital had hit a speed bump, morale was poor, and it was losing money. We quickly turned the hospital around financially and made a strategic decision to become a destination hospital and initiated five new product lines. Today CDH is strong financially, with EBITDA [Earnings Before Interest, Taxes, Depreciation and Amortization] margins of 18-20 percent annually, a credit rating that has been upgraded to AA, and growth in all product lines in a down market. On the clinical and patient safety side, we have been awarded Top 100 status by Thomson Reuters four times and received the President’s Award from Professional Research Consultants in 2010 for our top performance in patient, employee, and physician satisfaction.
This didn’t just happen magically. What did you do?
It has been a team effort. All of the new executives were familiar with the Chicago market, knew the competitive landscape, and were in a position to immediately take decisive action. We determined to become a destination hospital and implemented five new product lines, introduced new channels of distribution(i.e., the Cleveland Clinic), and instituted partnerships with a major university and a for-profit radiation therapy company (ProCure). Liz Rosenberg instituted the first change by establishing a partnership with Children’s Memorial Hospital.
You walked in and you saw the issues that this hospital system faced. What are the first three or four things that allowed you to turn this around?
One of the first things I did was assess the management team and bring in experienced executives familiar with the Chicagoland market. We then right-sized the organization, reduced 450 jobs and initiated a strategy to become a destination hospital. While all this effort was going on, we reengineered the patient experience, which has resulted in patient satisfaction being at the 94th percentile nationally. We had previously been at the 22nd percentile.
In initiating our strategy, we made major investments in the neurosciences and orthopedics. We formed relationships – joint ventures or partnerships – in other product lines. In the pediatric area, we formed a relationship with Children’s Memorial Hospital. In cardiac surgery, we signed an affiliation agreement with the Cleveland Clinic and in cancer we formed an affiliation with a local medical school and entered into a joint venture that allowed us to build America’s eighth proton-beam facility.
Due to our familiarity with the market, we knew CDH had a great medical staff with a strong workforce. We are very data driven, and it became clear from initial analysis that many of the hospital departments were overstaffed. We addressed how work was being processed and reduced staffing.
We do approximately 2,300 joint replacements annually. Before 2003, a surgeon could do two to three joint replacements in a day. Today, that same surgeon can do seven total joint replacements. Before, it was not unusual for a doctor to open up a packet of instruments and some were missing, causing surgery delay, more anesthesia, etc. Our goal was zero defects in surgery packs, and we achieved it. The effort was led by Robert Friedberg. He tagged and computerized the instruments and reorganized central sterile supply.Before 2003, a surgeon could do two to three joint replacements in a day. Today, that same surgeon can do seven total joint replacements. …Our goal was zero defects in surgery packs, and we achieved it.
We reengineered the processes for surgical patients. In the past, patients were told to come early in the morning and many times we were not ready for them. We flowcharted the process, and eliminated waste and unnecessary steps. The end product was that work was carried out much more efficiently. It didn’t happen overnight, but took several years of work. Because we’re a surgically oriented hospital, the number-one complaint I had when I came here was how the ORs worked. I haven’t had a surgeon complaining about this in four or five years.
We have a neurosurgeon who’s an unusually gifted doctor. He was in a group talking about these changes the other day. He has been a surgeon all his adult life, now in his late 40s, and said he recently went down to where they put instruments together. “I never knew how complicated that was.” He said, “I was always just asking for something and expecting it to be there. Now I understand what it takes to make this happen.”
We recently signed an affiliation agreement with the Cleveland Clinic, which we hope will raise the service and intellectual standards in cardiovascular services. We have been spending a number of years building out our capabilities in cancer. Since we’re just beginning to execute (just opened the facility three weeks ago) we haven’t seen the results yet. But we have set a great foundation in place. We also entered into a joint venture to construct and operate America’s eighth proton-beam center. In Seattle, your famous Fred Hutchinson Cancer Center has just entered into a similar agreement. With this technology, we hope to position ourselves entirely differently in the market, not only in high energy space, but also in diagnosis and treatment of cancer patients.
Mergers and Acquisitions
You have also done some acquisitions, is that correct?
We are scheduled to close on our first merger in late spring of this year.
In my experience, the challenge of these acquisitions is the culture. You can put all the numbers together, but it’s a question of how the cultures come together. What are you doing about culture?
In our case, we are merging with a hospital that is significantly smaller than we are, in a community that is contiguous to ours. Due to their geographic location, we already get many tertiary referrals from them.
Liz Rosenberg [LR]: In spite of the cultural differences, they still have the same kind of ambition to be top performers and have high patient, employee, and physician satisfaction. When you line up the words, we all have the same kind of vision for the patients, engagement in the workforce, and making the workplace for the physicians a place of choice. In terms of how we’re going to go about practically aligning the cultures, we’ve talked about engaging cultural organizational experts on that. We look at this, just like we’ve looked at a lot of the disciplined processes of building an oncology program or a heart program. We have to have equal open-mindedness and do our research so we can bring along a management team, workforce, medical staff, and the board together. We’ve been thinking about engaging someone with fresh eyes to help bring us together collectively.
In our case, there is a consideration that is a bit different from a for-profit company. There’s no stock, there’s no money, and the way the boards looked at it, we’ve focused on our mission statements. What are our ambitions? What have we achieved? They did things better and faster than we did. They were a magnet hospital. [A magnet hospital must meet over 65 standards developed by the American Nursing Credentialing Center (ANCC).]
[LR]: They have a service platform they had invested in. They had implemented with a lean methodology that Virginia Mason is so famous for. We had made a visit to Virginia Mason about two years ago and just started our own implementation.
Ethix had a Conversation with their CEO, Gary Kaplan, recently.
[LR]: On paper, our merger partner is very similar to us, but practically we have to knit together two organizations, two workforces, and two different medical staffs.On paper, our merger partner is very similar to us, but practically we have to knit together two organizations, two workforces, and two different medical staffs.
In my own experience with The Boeing Company, when they merged with McDonnnel Douglas, the words were all the same, but the style and what the words meant to people were different. I came up with this medical analogy that a merger is like doing a heart transplant. The culture is like the immune system. In order to make the heart transplant work, you have to suppress the immune system, otherwise the patient will reject the heart. But suppressing the immune system makes the person vulnerable to all sorts of illnesses; even a cold can kill you. Similarly, suppressing the culture when creating the new business means the natural culture that used to protect you is gone. The business becomes vulnerable to all sorts of things. Boeing had a CFO that ended up in prison coming out of that merger. My experience is that this is much more difficult than most people think.
We are focused on closing the deal. We also have an underlying belief that culture trumps strategy and in planning for the integration of these two institutions we are always trying to keep this foremost in our mind.
One of the things that we’ve learned is that when a person is confronted with change usually the first thing they see is the loss even if the net is going to be a gain. It’s human nature to see the loss. When you put two benefit packages together, this one’s got better this and that one’s got better that. You can’t pick the best of both plans because you can’t afford it. So when you put it together everyone will see a loss and they will focus on that. It’s just one of those simple little things that comes out of this process. I’ll be really interested to watch how you deal with it.
Our compensation program for our workers is significantly higher than the hospital with which we will be merging and we realize that aligning that will be disruptive. We haven’t figured out how to do it, but know this will be a big issue.
On a positive note, when the proposed merger was announced, their employees applauded the move because they realized that their size dictated that they either affiliate or merge with another entity.
What have you done that creates a culture where people seem to embrace change?
The approach has been multi-factorial. The process has been transparent. We openly address and support continuing what is efficient and talk directly about what could be better. We have significant input from our physicians and our employees in addressing what can be better. In simple terms, through that process we get more buy-in to the change people want.
Big Issues in Health Care
What do you think are the biggest issues facing health care today in the U.S.?
Number one, there is a disconnect between expectations and reality. Many persons have an insatiable desire for better health and many don’t want to pay for it. They want the government or the employer to pay for it. This may lead to more rationing, and we are not sure that the majority of people will tolerate this. Another thing I’m both excited and concerned about is the implication of all the change that is occurring or will occur, recognizing that there will be an enormous potential to increase the quality of life of our patients, without addressing the question of who will pay for it. For example, there are 1,000 new laboratory tests awaiting approval by the FDA right now. From a clinical and commercial sense, it offers great opportunity. Yet, again, because of the potential for not being able to pay for it, will this lead to more rationing?
And if you combine the test issue, which you just mentioned, with the other technology issues as well, don’t you amplify both the possibilities and the cost concerns?
We are excited, yet concerned, about the enormous change that science and technology breakthroughs will bring to the delivery and cost of health care. Unquestionably, yes. Another thing that we are excited, yet concerned about, is the enormous change that science and technology breakthroughs will bring to the delivery and cost of health care. A great example of this is the proton beam and its application for children with inoperable brain tumors. Their parents are faced with the chance of letting their child die or letting him have radiation. If they have radiation, in general they lose 20 to 25 percent of their IQ. If they have the opportunity to have the proton beam, because of the better technology, the reduction in their IQ is in the 3 percent range. Therefore, almost all parents would choose the proton beam over traditional radiation therapy. The machine itself, however, costs $90 million and the question is, who will pay for it?
Learning From Other Industries
What do you do in terms of learning from other industries? In what way can you, in the health care field, learn from manufacturing and other industries?
Our board members have been very open to introducing us to approaches industry has followed that have created efficiencies. In our case, we are fortunate to have Bill Pollard as our board chairperson, who sits on many public company boards, including Herman Miller. In that case, he provided introductions to their executive staff, who shared what they have learned.
[LR]: They were really gracious in having about 25 of us up there for several days to learn from them, and it was fantastic.
It is changing the way we look at things and is particularly helpful as we look at lean practices.
[LR]: There’s also a lot to be learned from the hospitality industry about service. We have looked at what the hotel industry has done in terms of service and what Disney has done. Health care people can learn from many different industries.
As another example, we learned from Four Seasons. They had developed a tool for selecting people who clean the rooms. We learn from others as often as we can.
As you bring new technology into the hospital, it changes a lot of things. It isn’t just cost, but it also affects what people do. If you replace one solution with a different kind of solution then people’s jobs change, and everyone needs to be retrained. How do you go through that transition of reeducating people to take advantage of new technology?
We are currently investing $100 million in a new information system. This new system will address how orders are written and reports are delivered and aspects of clinical documentation and a new financial system. Today, a doctor comes in, writes in a chart, then we pay somebody to transcribe the order, and manually input it. In the new environment, the doctor will do his own order entry, and we believe it will lead to fewer errors, less delay, and more accuracy. Our medical staff is composed of both employed and private-practice physicians and all have agreed that everyone will be expected to enter their own orders. We expect this to also deliver great economic savings to us.
Do you use bedside bar coding here? And what did it take to get started?
We do use bedside bar coding. The application of this tool has cut down on the number of errors associated with inappropriate drug administrations. We believe this bar coding led to a much safer environment, but we have not had any efficiency gains.
It took a great deal of in-service training and discipline for the nurses to accept the new processes and procedures to be followed in bar coding. At times it was a painful transition, but today our nurses wouldn’t want to live without it because it assists them in delivering safe care.
Bar coding is typically associated with an oral medication, but the most dangerous medications are the intravenous medications. So we went to smart pumps. Smart pumps have artificial intelligence that is used to establish guidelines so that the amount of fluid medication being administered is monitored both by type and dosage. These smart pumps have led to a much safer environment. We believe both bar coding and smart pumps have helped us reduce our risk-adjusted mortality rates from 1.18 to .56. [More than 1.0 means the hospital mortality rate is higher than others in the comparison group, less than 1.0 means it is lower.]
Speaking of process, do you use checklists in surgery here?
Yes, we do. That’s a great example of copying from the airline industry. We have plagiarized from them and have established a series of checklists that are used in all our operating rooms. Again, we believe this has helped us avoid mistakes and create a safer environment for our patients. Are you familiar with the book by Peter Pronovost, Safe Patients, Smart Hospitals? We have drawn extensively from that book in our implementation. [See review in this issue].This seemingly logical advancement [checklists for surgery] at first was met with great resistance from our surgeons.
[LR] This book was so powerful. We had the gentleman [Pronovost] speak at our board retreat. At those retreats, we include our board and about 50 to 60 members of our medical staff. We use it as an opportunity for dialogue between members of the board and the medical staff. He was just a spectacular speaker, focusing on quality and safety and what needed to be done differently. Our medical staff is still talking about him and what he did at Johns Hopkins University Hospital and the applicability of the lessons to us. He is a humble man, a practicing physician, and anesthesiologist, and he is passionate about hospital safety.
I first read about checklists in Atul Gawande’s Checklist Manifesto [see review in issue 68]. He talks about the huge cultural issues associated with using checklists because of the implications that different members of the operating team can stop a procedure if a step is skipped.
After we learned about checklists from Atul Gawande’s Checklist Manifesto, we sent nurses to lectures he was giving, reviewed the literature, spoke with the heads of our surgery departments, and agreed to implement checklists. This seemingly logical advancement at first was met with great resistance from our surgeons, and it was through the prodding of our nursing leadership and our director of surgery that the checklist procedures were eventually accepted.
Tell me about the moral and ethical issues that you see in health care today?
There are so many different perspectives. For example, one challenge comes when a family is spread out across the country. We see a father or a mother in their 80s with a stroke. They’re on a ventilator and their son or daughter is in Seattle and they’re confronted immediately, by phone, about whether to keep their parent on life-support systems. Many times people haven’t thought about that, or talked to each other about it. We try to guide them but it is their choice how to handle end-of-life issues. The end-of-life decisions are complex and have many moral issues. These issues have great effect on the caregivers.
Is there a moral issue in the area of access? Some people don’t have insurance, or can’t afford it.
We have modified our charity policies, making them more liberal. In our market, if a family of four earns $80,000 or less, they are not charged by the hospital if they have no insurance, and we have a sliding scale for persons making more money than that. It is because of our financial strength that we were in a position to make those changes.
Health Care Law
My concern would be that emergency care is expensive and comes after the health issues have become complicated. In part, I thought the new health care legislation was trying to deal with this. How do you see the new health care law?
We are constantly trying to learn more about the implications of “Obama Care,” but given the regulations haven’t been published, it is very difficult to estimate the implications of these changes.
Do you think it’s a step in the right direction, a step in the wrong direction? How do you view it in broad terms?
In broad terms, the effort is essential. We can’t afford to spend as much of GDP on health care. Fee for service works sometimes but many times it reinforced bad behavior and over utilization. It makes sense for organizations to be accountable, not just for the emergency room, but for the entire individual’s health. The dilemma is how it is going to be implemented and what the incentives are.We can’t afford to spend as much of GDP on health care.
As you are learning, what do you think the biggest changes will be for you?
We have good alignment with our medical staff today. But many doctors entered medicine for all of the right reasons, and we’re operating in an environment where they were paid on a fee basis. That may disappear as the doctors become partners in ‘bundled-payment’ arrangements. We have a fair amount of anxiety on how to navigate the transition from fee-for-service to bundled payment, and not only keep our alignment with our doctors but actually to improve it. It is complicated by two things: The government has not said how this will be implemented, and with the recent elections and the noise that the Republicans are going to get this repealed, it’s harder to get people’s attention.
So it’s a transition time, and you’re facing that in the midst of all the other things you’re trying to do.
Health Care Costs
What about health care costs? You obviously have been very effective at that because you reported on the numbers, but what are the big cost issues associated with health care?
Let’s take the cancer product line as an example. There are many promising drugs continually coming on the market. The hope is that they will help people, but they may be extraordinarily expensive. The only way we will deal with it is to try to achieve greater scale. Scale has always mattered in health care, but now scale is going to mean more than ever before for safety, quality, and cost. We look to lean process improvement to help us with process. We need to work faster, smarter, and simpler. Like any factory, we need good, functional relationships in every department so work flows better. That’s one of the reasons we’re spending on new facilities.
What about the issue of malpractice? Is that a cost factor that is of concern to you?
We don’t think it’s the primary one. It’s a big political issue, it’s something that has to be dealt with, but on a day-to-day basis it is not a top of the mind issue. However, if you’re a neurosurgeon or an obstetrician, you have to work half a year before you’ve paid for your malpractice insurance. That makes it a real issue for them and ultimately us.
One of the things about health care that seems to be an anomaly compared with other industries is that someone with a health problem doesn’t care what it costs. If they have insurance, they don’t care what it costs because they don’t see the cost. How do you motivate cost control in this environment?
We have a fair amount of anxiety on how to navigate the transition from fee-for-service to bundled payment.
Navigating the health care system is difficult. When I become a consumer, or a loved one of mine becomes a consumer, it always reminds me of how hard it is to know where to go, where to get the best care, and how to navigate through the system. It’s unrealistic to think that the person who consumes health care is going to be able to deal with price at the same time. Yet it’s our responsibility to operate the hospital in the most efficient way. I don’t think we can depend on them to care about the cost.
Obviously there are economists who believe differently. There are these health saving plans that want people to pay first dollar to urge patients to shop for better prices. But when you’re suddenly acutely ill, shopping for price may not be practical.
Are you familiar with Atul Gawande’s article in The New Yorker, “The Cost Conundrum,” where he looked at two cities in Texas, 50 miles apart? They had very different economics for health care in cities that served similar population types.
Yes, I am familiar with it.
When I first read it, I found the difference so remarkable I almost didn’t believe the article. In our market, I don’t think the price differences are that profound. On the other hand, the Cleveland clinic, for example, does bypass heart surgery on average at about 25 percent lower cost than any tertiary-care center in Chicago and has better outcomes. There are providers that are delivering great care at distinctly lower costs.
I would like to ask a similar question at a more macro scale. In America, the cost of health care per person is substantially more than anywhere else in the developed world, but the outcomes are not as good. From what I have read, longevity, infant mortality, quality of life, all measure less than they do in many of the other places where health care costs are less. Can you comment on why that might be the case, or if you even believe the numbers?
I have not studied this, and even if I believe the numbers my answer would only be speculation. Comparing America to Ireland or the Scandinavian countries, it appears that we have much more violence, our populations are not as homogeneous, and their citizens appear to be more willing to tolerate queues for health care. I have also been told that in many of these countries if you have above-average wealth you don’t use the public system.
The numbers are really curious if you look at the graphs. Even the infant mortality rate in Cuba is better than the U.S., according to data I have seen.
In 1968, I remember that everybody was talking about our spending in a similar way. Sweden, as an example, had lower costs and better results. As students, we were attending a lecture by the head of the Swedish health administration. It was canceled because his wife was having a baby, but he came back three months later and explained the Swedish health system to us. Somebody in the room asked if his wife had had the baby at a private hospital or the public hospital. Interestingly, he reported that his wife had their baby at a private hospital.
If you were on assignment for Boeing in China and got sick, would you get medical care there, or fly back to America? I bet you would fly back if you could.
How do you look at the system of health care, making all the pieces work together? The patient must deal with the specialists, the pharmacy, and all of the other pieces, trying to make them work together. How are you thinking about making this a better experience for the patients?
There has to be a radical change. Patients are becoming better educated than ever before, with access to more information about their care. Nurses are becoming more knowledgeable, advanced practice nurses are better educated, and doctors are more talented.
We’re intrigued by Wal-Mart getting into the primary care businessWe’re intrigued by Wal-Mart getting into the primary care business. These changes are going to make access for diagnosis and healing minor ailments a lot easier. Today, people have to queue up and wait and pay a lot of money for even these simple things. We’re going to experiment and provide staff through Wal-Mart and change the model.
Clayton Christensen, in his book The Innovator’s Prescription, talks about the simple, routine parts of health care breaking off into other kinds of delivery. Nurses will take on more of the primary care here. Our goal is to be the destination “factory” for the difficult cases, but have alternate delivery for the other parts of the system. We believe in all that and are working toward it.
Most doctors are not taught these things in school. So how do you think medical education will change toward more processes and systems?
Some of this is happening now, but not enough. A person goes to medical school and because of the necessary learning becomes incredibly specialized. They learn how to make decisions independently and normally are not taught how to work in groups. When they are put into a hospital setting, their training at times works in conflict with the teams they must play a role in.
In addition, hospitals have not been attracting the top graduates into their management ranks, most likely because of the imbalance in the risk/reward relationship. One of my biggest fears is that this gap will widen and we will become more unattractive to young people interested in management.
How do hospitalists fit into your system?
Hospitalists have been an important step forward for complementing the way our primary-care persons want to work. They allow our primary-care physicians to stay in their office to be more productive and at the same time the hospitalists, because of their limited number compared to the size of our primary care sections are more familiar with the hospital’s workers, processes and teams, and typically help improve efficiencies.
For many of the primary-care persons, hospitalists have made them more efficient. Hospitalists mean we have someone who is there at the hospital rather than off at another practice. We have people who know our systems and know our people, and this improves safety.
In one of our critical care units, patients are seen by people who have done residencies or fellowships, and that’s all they do. They’re not paid on a fee for service basis.
In 20 years, how will health care look different than it does today? Consider technology, legislation, and political environments.
Health care will be delivered in a radically different way. I believe that nurses and advanced practice people will take over primary care. The distribution system for how people deal with non-critical aspects of their health, like strep throats, fevers, and shots may be done through a distribution system like Wal-Mart. There will be a third less hospitals. Hospitals will be bigger and they’ll be fewer of them because scale matters so much. I think we will still attract the best people in America, because, except for being a priest or rabbi, what profession offers a better way to truly help people?
It wasn’t very attractive to become a nurse for a long time. As we come out of this recession, we don’t have enough Ph.D.s to produce enough nurses. To compensate, the requirements to get into nursing have grown substantially, taking out many well-qualified candidates. That is a flaw in the system. Today we hire only graduate nurses with a bachelor’s degree, though we used to hire nurses with two years of training. We have to start rethinking what is required at each level of the health care system. Unless we go into a depression, the demand for better health will continue and, for better or worse, we’ll continue to be a big part of the gross national product.
We need people who have very different educational backgrounds as well. Liz and I work with a woman who was a great athlete at Stanford and went into the consulting business with a high-powered firm. Then she made the odd decision to go to Johns Hopkins and get a degree in nursing. We need people like this.
We also need well-trained administrative leaders. Liz is a good example of what I mean. She brings a lot to the hospital, but does not have the traditional medical training. She went to Harvard, majoring in Russian, and then worked for a think tank. How many people in your class ever thought of working in a hospital?
[LR]: In my graduating class there were three people who studied something related to health care. Most went to Wall Street. Some became lawyers. I then went to Wharton thinking I would go into international business. But I got lucky and found a career in hospital administration.
We have wonderful jobs, we get paid well, but we have a hard time finding people who meet our expectations. Finding good people is a challenging factor for our growth.
What motivates you to do this work?
I believe hospital administration, like most work, gives dignity to your life and the opportunity to work in a hospital setting with such a diverse work force is simply fascinating.