Kevin Van Renan

J. Kevin Van Renan began his career at Mary Washington Healthcare (MWH MediCorp) in 1995 as the Director of Cardiac Services. In 2006, he began serving as the Senior Vice President and Administrator of Mary Washington Hospital. He retired from Mary Washington Healthcare in 2014. Van Renan’s career in health care began in 1976 at Bryan Memorial Hospital in Lincoln, Nebraska. While a student at the University of Nebraska he worked as a nurse’s assistant. He later worked as a respiratory therapist and a registered nurse. He received a bachelor’s degree and a MBA from the University of Nebraska.

J. Kevin Van Renan was interviewed by Jess Rigelhaupt on July 30, 2014, and October 14, 2014.

Discursive Table of Contents

Interview 1
00:00:00-00:15:00
First day at Mary Washington Hospital in 1995—Starting as Director of Cardiac Care—First open-heart surgery at Mary Washington Hospital was on November 8, 1994—Development of cardiac program—Cardiac program began Mary Washington Hospital’s transformation into tertiary care hospital—Working with Dr. John Armitage, Medical Director of Cardiac Surgery

00:15:00-00:30:00
Building the infrastructure for cardiovascular patients—Van Renan’s career in health career: began as a nursing assistant in 1976, to respiratory therapy, to RN—Career at Bryan Memorial Hospital in Lincoln, Nebraska—Advances in medical and cardiac care, 1976-1995—Cardiac surgery not in isolation and coordination of care

00:30:00-00:45:00
Organizational values—Focus on community needs—Strategic planning for community health care needs—Dynamics between the board, administration, and physicians

00:45:00-01:00:00
Expansion of Mary Washington Hospital—New opportunities for nurses at Mary Washington Hospital—Recruitment of clinical nurse specialists—Finances at Mary Washington Hospital in mid-1990s

01:00:00-01:15:00
New hospital and continued physical expansion in the first decade after it opened—Growth evolution of the cardiac program—Higher patient acuity—Higher level care in the ICU—New operating rooms

01:15:00-01:30:00
Planning for new operating rooms, ICU beds, cardiac services, and the electrophysiology laboratory—Development of cardiac surgery at Mary Washington Hospital

01:30:00-01:45:00
Preventative medicine—Keeping people out of the hospital—New cardiac care and medicine, in addition to open-heart surgery—Communication and education about new practices and new ideas

01:45:00-01:54:27
Telling the story of new cardiac practices to the community—Influence of the cardiac surgery program on other programs—Physician-hospital collaboration to spur innovation

Interview 2
00:00:00-00:15:00
Era of growth, 1995-2000—Expanding campus infrastructure and satellite buildings and programs—Hospitalists—Expansion of medical staff and nurses

00:15:00-00:30:00
Communication with primary care physicians—Providing higher-level medical care so people in the community did not have to travel to Washington, D.C., Richmond, or Charlottesville—Development of neurosurgery and trauma programs—Development into a tertiary care hospital

00:30:00-00:45:00
Values, mission, and transition into a tertiary care hospital—Discussions with senior executives about the mission, values, vision for the future—New communication methods—Promotion to vice-president of clinical operations in 2000

00:45:00-01:00:00
Experiences as vice-president of clinical operations—Supervising the development of new clinical programs—Working with Walter Kiwall, COO, and Fred Rankin, III, President and CEO

01:00:00-01:15:00
Development of Home Health and Hospice—Health care business models

01:15:00-01:30:00
Investing for growth—Managing hospital finances—Promotion to Senior Vice President and Administrator of Mary Washington Hospital in 2006

01:30:00-01:45:00
Creating a senior leadership team—Challenges since 2006—Stafford Hospital—Achievement of Nursing Magnet Status—Career milestones—Community benefit practices

01:45:00-02:02:48
Community benefit—Grants to outside agency through the Community Benefit Fund—Intersection of the mission, primary care, and preventative care—Influence of external forces, such as CMS and bond markets—Continuity in the mission and values—Interview concludes

Transcript

Interview 1
01-00:00:00
Rigelhaupt:
It is July 30, 2014. I am Fredericksburg, Virginia, doing an oral history interview with Kevin Van Renan. And to start the interview I would like to ask you if you could describe your first day at Mary Washington Healthcare.

01-00:00:22
Van Renan:
My very first day was in actually July of 1995. I was recruited from a large heart hospital in Lincoln, Nebraska, Bryan Memorial Hospital, to be the health system’s and Mary Washington Hospital’s first director of the cardiovascular service line. That first day, in making the turnoff of Route 1 onto Hospital Drive, just to see the beautiful facility and grounds was very, very special for me. I think one of the things that really stood out was the people that I met on that first day. It was amazing how many of them reminded me of colleagues that I had worked with at Bryan Memorial Hospital. Sometimes they were in a different job, but they were clearly very special, very passionate about the work that they did. It was an exciting first day to come be a part of the Mary Washington expansion.

01-00:01:32
Rigelhaupt:
You mentioned people you started working with. Who were some of those people that first day?

01-00:01:38
Van Renan:
My first day, the lady that actually helped recruit me here, Neda McGuire—Neda has continued to be a dear friend and has been a successful businesswoman in the Fredericksburg community. Neda was the one that helped convince me to come to Fredericksburg. She had the responsibility to get me oriented to my new responsibilities and to get to meet, reconnect, with physicians that I got to meet in the interview process. Also Barbara Kane and Sue Hall, both who were senior nursing leaders with Mary Washington Hospital, were important contacts for me early on and helped make sure that I was getting myself welcome and indoctrinated into the health system. They, too, have remained fast friends. Both have since retired from the health system.

01-00:2:52
Rigelhaupt:
What were your first responsibilities as director of cardiac care?

01-00:02:58
Van Renan:
I had service line responsibilities. [03:00] All the things that went into cardiovascular care: that would be our cardiac cath lab, electrocardiography programs, cardiac surgery, and our cardiac and pulmonary rehabilitation programs. I had responsibility for those direct services. I also had responsibility of where does the program need to go? It was in its early infancy. Within a matter of that first few months, we celebrated the first anniversary of the first cardiac surgery at Mary Washington Hospital. Some of the expertise and experience that I brought from my time with Bryan Memorial Hospital was about how do you build and position the cardiac program for future growth and success.

01-00:03:58
Rigelhaupt:
When you say that there was the first surgery, had the first open heart surgery happened here before you got here?

01-00:04:05
Van Renan:
Yes. It was November 8, 1994. This November, this coming November, we’ll celebrate the twentieth anniversary of that first cardiac surgery. So they were less than a year old of really a new era in cardiovascular care for Mary Washington Hospital, the Fredericksburg community, and surrounding areas. It was helping to position that program so that it could grow and do an exquisite job of caring for our community; what were the new services and technologies that we needed to begin to look at to offer?

01-00:04:54
Rigelhaupt:
So thinking about the months, I’m assuming it was months in between the time that you had chosen to accept the position and when you first started in July of 1995, what were you thinking about in terms of the goals for the cardiac program at Mary Washington?

01-00:5:10
Van Renan:
Certainly I tried to do some early homework. When I came from my interview in May of 1995, I had an opportunity over a course of a few days to meet and talk with not only physician leadership in the cardiovascular service line, but also other senior leaders to get a framework of what had been the conversations and some of the vision. I’m often asked, “Why did you decide to come to Fredericksburg from a very large successful cardiovascular program to start one from scratch?” One certainly was the community. I really fell in love with Fredericksburg and the Mid-Atlantic area. [06:00] The second was the professional challenge. I had never started a program from the ground floor. Probably third and most important, was my last interview with Fred Rankin, who was president and CEO of the health system at the time. I sat down in Fred’s office and he began to talk and describe his vision for the program and for the health system. He talked for probably a little bit over an hour and it didn’t seem like he took a breath during that time. You could see his passion and he really understood implicitly at our core the program and the health system. It was a people business and it was about people caring for people. You could see that he was going out finding others who had shared his vision. It was like he was rebuilding the health system one person at a time, one brick at a time. When you got to the end of that sixty minutes you say, “Wow. I want to be a part of that.” One of the things I really enjoyed over these nineteen years now has been being a part of making that vision come to fruition. It’s certainly been very satisfying to be part of that journey.

01-00:07:33
Rigelhaupt:
I know it would be hard to really put that last hour interview with Mr. Rankin into a box and talk about it specifically, but I’m going to try and ask you if you can remember back to that hour, if you can recall how he talked about the cardiac program fitting in with this expansion from a community hospital to a regional medical center.

01-00:08:03
Van Renan:
I think at that time it was that first really major step to say Mary Washington Hospital is beginning to offer services that the community up to that point either had to travel to DC, to Richmond, or over to Charlottesville. It was really that first tertiary level high tech service, and was that kind of first pebble in the pond that began to change the entire complexion and direction of Mary Washington Hospital. It was making that transition from being a very large successful community hospital to taking on much more of a tertiary level referral presence in the community. [09:00] I think it also set a bar, a new bar, for the medical staff and the associates to say, “We’re different now and there’s a higher bar that we need to strive for.” What are those other new services, things that only a tertiary center would begin to offer? I think that has helped propel the medical staff and helped propel our recruitment. Who are the types of associates, nurses, and other caregivers that really are necessary to this evolution?

01-00:09:40
Rigelhaupt:
Open heart surgery is incredibly complex. It’s a new program. Did you have discussions in the interview about the challenges that you as a director and the program itself would face as it was being built up?

01-00:09:58
Van Renan:
My interviewing of Mary Washington Hospital and the physician leadership at that time was trying to get a sense of what was their infrastructure? How did that match up? Did they have the right experiences? Our cardiac surgeon at the time was Dr. John Armitage. I knew of Dr. Armitage through the cardiovascular networks. He had an incredible reputation and certainly was very experienced. He brought members of his team from the University of Pittsburgh Medical Center as well. The cardiologists and others that were involved in the program at the time had the right infrastructure. They certainly had the passion and commitment to make the program successful going into the future.

01-00:10:54
Rigelhaupt:
So trying to stay with those first few weeks that you started, July of 1995, I think probably with every new position it’s a little bit different than what you imagined at the end of an interview. What were some of the things that you saw during these first few weeks that stood out, that you learned about the organization?

01-00:11:20
Van Renan:
Actually, the first several weeks was a lot of time just getting to meet people and getting to reconnect with members of the medical staff, nursing leadership, and individuals that I had responsibility of overseeing. I spent a lot of time in our cath lab, with our rehabilitation staff, with the nurses that cared for the cardiovascular patients, and really beginning to get a good understanding of how things were structured, what was the patient flow, and then comparing that against past experiences. Then what were those opportunities to kind of reconnect the team? [12:00] We would meet on a regular basis, several times a month, to say, “Here’s our progress. What are those new opportunities?” We began to put together a framework and a roadmap for success for the program. It was a very wonderful rewarding time for me professionally and it’s been satisfying to see a lot of those same faces still part of the health care team.

01-00:12:39
Rigelhaupt:
The team that you described meeting with a few times a month, who was on this team and how did you choose those people?

01-00:12:45
Van Renan:
Dr. Armitage and the cardiologists were critical to those conversations. Then looking at the continuum of care: from where the patient entered the health system and how they went up to the cath lab. You had cath lab representation. Where did they go for their post procedure care? We were pulling in that nursing staff, the surgical team involved with the cardiac surgery program, ICU nurses, and anesthesiologists. All those different elements you were trying to pull together around the table because everybody had a piece of the patient care process. Everyone had a unique perspective. Everyone needed to understand what was the ideal for them to receive the patient from the person up the chain, and what did they need to do to prepare their patient for the right handoff to the next person or team responsible for the care? It was starting those conversations and beginning to pull together a framework. Then also reaching out to other organizations, not just the organization that I came from, but others to look for what were best practices and what were new innovations. It was staying abreast of what was going on in cardiovascular care at that time.

01-00:14:26
Rigelhaupt:
So one of the things that I think marks—and please do correct me if I’m wrong; I’m actually testing a hypothesis here—that marks the transition from a community hospital to a regional medical center are the teams around surgical subspecialties. When it was across the street at 2300 Fall Hill, you would have a physician in charge of a patient, nurses taking care of him but not necessarily the same kind of teams that are required for something like the cardiac program. [15:00] Did you find you were building that team where nurses are going to contribute nearly as much as physicians? Was that something new that you saw within the organization or was that something that you also saw here?

01-00:15:20
Van Renan:
They had started that work in the months prior. By the time I joined the program it was looking for what were any missing pieces? What were areas that we needed to try to do some expansion or some additional education or get additional experiences? Caring for a higher complexity of cardiovascular patients, whether it was in the cath lab—because now with a backup cardiac surgery program they were able to keep and care for more complex patients that may have required quick intervention from a cardiac surgery perspective. The cath lab was doing new things. The types of issues that might come up with a critically ill cardiac surgery patient puts new strains. There is technology and other supports that you need to have in place to care for a broader spectrum of patient issues. It was continuing to build on our infrastructure. Then once that infrastructure was in place many of those actually can be applied to other more complex patients outside of cardiovascular care. So that let the health system begin to look at other tertiary level type services that they were offering.

01-00:16:45
Rigelhaupt:
Do you remember some of the first pieces that you identified, you and your team identified that you wanted to add over those first few months that you were here?

01-00:16:58
Van Renan:
There were simple things that we put into place that were very impactful. One of those was we had a one page roadmap for patients once they got out of the ICU. It described, in kind of layman’s terms, the things that we need to accomplish on day one, day two, day three. We were able to kind of script out four or five days. I want to say probably that first iteration was you were planning on a five day length of stay that would culminate in discharge and being able to go home and continue your rehabilitation and healing at home. That was different. It was something unique. It seemed simple to many at the time, but it was very impactful for patients. [18:00] Having that kind of script, they began to understand, including their family, you’ve got an important role. Some of this four to five day journey really became a dress rehearsal for home. With each successive day, as your activity increased, there were new things that we introduced for the family to get them to participate in the healing process so that family members felt relatively comfortable when they went home. I’ve had some opportunity to practice, I’ve had some opportunity to ask questions, and so I’m feeling better about what I need to do to help my family member continue to heal.

01-00:18:50
Rigelhaupt:
So I’m going to come back to the cardiac program, but I want to ask a few questions about your career in health care before you came here. So when we spoke earlier you described starting night work as a nurse’s assistant.

01-00:19:11
Van Renan:
Yes.

01-00:19:11
Rigelhaupt:
So I’ll just say if you could talk about how you began working in health care.

01-00:19:17
Van Renan:
My health care journey started in September of 1976. I was studying chemical engineering at the University of Nebraska and I needed a job that I could work full-time nights to help pay for my education. Working in a hospital is one of those unique environments. My first health care job: I started as a nursing assistant working nights. I made $1.76 an hour. I think that included my twelve cent an hour night differential. I eventually got to my junior year of my engineering education and it was getting harder to imagine being a chemical engineer for the rest of my life. One of the things that really stood out, even as a nursing assistant, was I had an opportunity to feel very special at the end of each shift and that I’d made a real difference in somebody’s life. My spirit was being drawn to health care. I wasn’t quite exactly sure what I wanted to do, but I made a decision to make a sharp left turn in my vocation, in my education, and to go into health care. I went on to get an associate’s degree in respiratory therapy. I’m a respiratory therapist. That allowed me to get a slightly better paying job. I went on to get a degree in nursing; I’m a registered nurse. It actually wasn’t until mid-career that I got my first leadership opportunity. I saw that I had an interest and an ability in leadership. That sent me back for some special education and I have a master’s in business, as well. [21:00] It’s been a wonderful journey for me since 1976. Certainly it has been helpful in my current responsibilities as a hospital administrator to have a solid clinical foundation. I have not been at the bedside in quite some time in direct patient care, but I do understand the science and I can sit down with nursing staff. I can sit down with other clinical staff or medical staff and have clinical conversations and they know that I’ve been in those shoes at some point in my career.

01-00:21:39
Rigelhaupt:
Could you talk about the different clinical positions that you’ve held? Could you talk about the different clinical positions?

01-00:21:49
Van Renan:
As I said, I started as a nursing assistant and then was able to get my respiratory therapy education. That allowed me to go into respiratory therapy. Then I started as a respiratory therapist and spent actually much of my time in our cardiac surgery, kind of a post-ICU care unit. That’s where my love for cardiovascular care began to flourish. I got to a place where I thought I wanted to go into anesthesia. Getting my nursing education was going to be a nice marriage between my respiratory therapy background and allowing me to position myself to go onto anesthesia care. I went to the University of Nebraska Medical Center for nursing and within a matter of months of me graduating they moved the anesthesia program from Lincoln, Nebraska to an affiliation with Drake University in Des Moines. If I was to continue that educational track, I would have had to have gone to Des Moines for six months, Lincoln six months, back to Des Moines, and back to Lincoln. By that time I had a family and a mortgage and that just wasn’t going to be in the cards. I actually went on to take a nursing position in the cardiac cath lab and so that continued to foster my interest in cardiovascular care. I also had, after that time, some opportunity to go back on the respiratory therapy side to manage their critical care programs. That built on my leadership interest and kept me very connected with critical care medicine.

01-00:24:00
Rigelhaupt:
So this is roughly between 1976 and 1995?

01-00:24:07
Van Renan:
Yes.

01-00:24:08
Rigelhaupt:
All these different positions.

01-00:24:10
Van Renan:
Yes.

01-00:24:10
Rigelhaupt:
And they were all at Bryan Memorial Hospital?

01-00:24:11
Van Renan:
Yes, in Lincoln, Nebraska.

01-00:24:14
Rigelhaupt:
And speaking of clinical care, what were some of the innovations you saw in cardiac care over those eighteen years or nineteen years—

01-00:24:27
Van Renan:
That’s a great question. I remember when we were doing our preoperative teaching for cardiac surgery patients. You would sit down with that patient, who certainly was very anxious about going and having cardiac surgery, and their family, and you began to kind of describe how the care would take place after surgery. Typically what you would tell them, “For the first twenty-four hours you’re going to come back to our ICU. We’re going to keep you asleep for probably the entire first day. You’ll be mechanically ventilated. We’ll do the breathing for you. We’ll begin to wake you up after that first day. Then you’ll probably be in our ICU for upwards of four to five days. And if everything goes well, then we’ll move you up to our post-ICU care unit where you might spend another two to three weeks. So you are looking at the better part of three to four weeks of post-operative care.” Today, having that same patient and same post-operative teaching, you would tell them, “You’ll come back to the ICU. We’ll begin to wake you up probably after the first few hours of your surgery. Pretty good chance within the first four to maybe eight hours we’ll get you extubated. You’ll be breathing on your own. Then certainly within the first twenty-four hours you’ll be out of the ICU. We’ll take you to our step down unit. We’ll begin the rehabilitation process. You’ll probably be there three to four days and then we’ll be sending you home. You’ll be prepared, along with your family, to be able to continue your care at home.” The majority of patients are home in anywhere from five to maybe seven days. Very, very different. It wasn’t so much special technologies, but you learned new ways to help the patients heal, prepare them better, and the work that needed to take place in surgery and the ICUs to allow patients to go home. At the end of the day they wanted to go home. They wanted to be with their families. [27:00] They could continue a lot of the work that we used to try to do that took matters of weeks in a hospital stay. So a very, very different patient experience. Also in that time, there have been innovations in the cath lab. Patients back in ‘76 and certainly up into the early ‘80s—cardiac stenting and putting that wire infrastructure in a heart vessel to help open it up wasn’t available. When you got to where there were significant blockages, really cardiac surgery was your only option at that time. Much of the early innovation has taken place in the cath lab. That hopefully postpones, at the very least, if not prevents patients from having to go on for cardiac surgery at some point in their life.

01-00:28:02
Rigelhaupt:
So it sounds like the less time in the hospital, three to four weeks to a few days potentially, is both surgical in terms of different procedures that are available, but also in post-operative care. Do you recall, as you were starting here, who was leading the innovations in post-operative care? I imagine the surgical care is being led by the cardiac surgeons. But the post-operative care involves many people and is a multidisciplinary team. Where were some of the innovations coming in terms of post-operative care as the cardiac program is built up here?

01-00:28:55
Van Renan:
I would still link that back to Dr. John Armitage, who was the chief of the surgical program at that time. Dr. Armitage in his experience in Pittsburgh was very connected and well researched in new innovations and where cardiovascular care and surgery was going, including post-operative care. He helped with leading those conversations. He would be sitting down with the ICU team. It would be the ICU nurses, the respiratory therapists, and the anesthesiologists that were helping from an intensivist perspective. He would be sitting down with the nurses that were in the step down unit and the rehabilitation staff to help them understand where the industry is going. Here’s how our program is going to evolve. Here’s the important role that you have in this continuum of care. He was kind of the critical lynchpin of making all those different connections. [30:00] It’s all these different interconnections that make the program ultimately successful. It’s not just cardiac surgery in isolation. It’s not just ICU care in isolation. It is a coordinated team where there is a very prescribed sequence that you need to go through to get the best possible outcome for the patient and their family.

01-00:30:27
Rigelhaupt:
The coordination and the synergy you’re describing in a continuum of care around the cardiac program, did you see that in other surgical programs within the health care system, or was this something that the cardiac program was really leading within the system?

01-00:30:48
Van Renan:
This was the cardiac program leading in the health system. And certainly from my experience at Bryan Memorial it’s what I was used to in how patients were cared for at Bryan. It was pulling together those best practices that were out there, that were very well researched, and have strong foundations to say, “If you follow this sequence, the majority of times you are going to get a very good outcome. Here are the timeframes that you need to work in. Here are the types of supports that you would need along the way.” It’s very evidence based.

01-00:31:30
Rigelhaupt:
Was that new within the health system, the emphasis on evidence-based medicine?

01-00:31:35
Van Renan:
I wouldn’t say the emphasis on evidence-based medicine. You certainly saw that in many other aspects of the health system. This was probably that first opportunity to have such a complex series of interconnections, where you’re bringing in lots of different disciplines in a complex patient care situation. It really help set a new framework that we could potentially replicate in other patient care opportunities.

01-00:32:13
Rigelhaupt:
I’m going to switch direction just a little bit. I’ve heard in these interviews a lot of discussion about values of the organization and I’m wondering if you can think back to the first few months, maybe the first year. It’s probably hard to put into a specific timeframe, but what do you remember learning about the values of the organization as you began?

01-00:32:39
Van Renan:
I’ll go back to that last interview and my time with Fred Rankin. Fred really understood, at our core as a hospital and as a health system, we’re a people business: people caring for people. [33:00] Part of that heritage that he inherited from other leaders before him and he’s carried forward throughout his career is this strong connection to the community. We were started by community leaders back in 1899 and throughout our history—this coming September will be the 115th anniversary of Mary Washington Hospital. It’s been the strong connection to the community that really has been core to who we were as an organization. Part of that value system has been we take that responsibility very seriously. We’re blessed with the opportunity to have a growing community to care for. It’s really guided the health system in its growth over the years. In that kind of people orientation, values and the framework around our values have been very people based. It’s about integrity. It’s about caring for the community. It’s that commitment to excellence and respect for the people that we work with and the people that we care for. It has been critical to our growth. It really is our compass that guides us today and guides us into the future of how we are and the personality of our organization. You look for other leaders. You look for associates that are involved in patient care. You look for physicians that are coming with those same sets of values. Back to that interview with Fred where I began to see or got the impression he was going out finding people that shared those same kinds of values one person at a time, one brick at a time, and he was building this new health system.

01-00:35:21
Rigelhaupt:
Correct me if I’m wrong about this, but it seems that it might, for lack of a better word, be easier to maintain a connection to a community and stay community focused when you’re a small community hospital. And at the exact time you start here this organization is now doing programs that rival university hospitals in terms of cardiac care and expansion. Literally, the building we’re in is a marker of that expansion. [36:00] What are some of the ways that you can recall over the first year that the organization maintained its focus on the community at the same time it was expanding to an incredibly complex medical fields and surgical subspecialties?

01-00:36:12
Van Renan:
Throughout my time with the health system, several times a year you are going through conversations and formal assessments of what are the needs of the community? What are the various health care needs? What are new emerging needs? What are the things that are taking patients from our community out of the community to go seek other services? Then beginning to try to understand, is this something that we can put together ourselves? What I would offer and say about 1995 to the current is one of our greatest challenges actually has been keeping up with a growing community and growing demand because you can’t build new hospitals and all of this new infrastructure overnight. It takes lots of planning, preparation, and making sure you’re offering the right services at the right place and at the right time. That was kind of part and parcel to Fred’s philosophy and this connection. The strong connection to community was taking on that responsibility. We needed to evolve with the community and grow with the community. As the needs began to change, we began to reposition ourselves as a health system. One of the things that started in the 1990s and continues forward was trying to move as many outpatient services as possible off the main hospital campus. Up until that time, you were very hospital campus centric. With a growing community and as the surrounding counties began to expand, the geography began to change and growth became very clear. It was difficult, if nothing else, from a traffic perspective to get here for care sometimes. What were different locations that we could begin to take different services and move them out to the community, closer to the patient and their family to make it more convenient for care?

01-00:38:45
Rigelhaupt:
The commitment to the community in providing health care to the community is a core part of the organization’s values. [39:00] Can you think of ways that the organization tried to maintain that focus internally in terms of in an era of expansion? How do you maintain that culture that is focused on providing health care to the community?

01-00:39:14
Van Renan:
Certainly through our strategic planning process, through our conversations with the medical staff, and our conversations with the associates. You’ll hear the word community come up time and time again and everyone begins to make the connection. We exist because of our community. We were started by our community. Our success into the future is dependent upon that kind of connection. Certainly that has helped guide us. Whether it be a new tower additions—when we opened the new 100-bed tower at Mary Washington Hospital back in 2004. You had to add a hundred beds to Mary Washington just about ten years after moving into the new facility. Community: that community focus and community need were central to the conversations. Today, as you look at the things that we are trying to accomplish and we talk about the different goals and objectives and our strategic plan, community is central to all the different themes. What’s going on in our community? What’s our responsibility in changing responsibilities? Now you have got other care opportunities out in the community. How do we need to continue to evolve so that we are providing the right services for our patients and community today and going into the future?

01-00:41:10
Rigelhaupt:
So thinking about what you remember about discussions of the community in how the health care system is going to provide needed health care for the community in that first year you’re here. Do you remember if it was physicians advocating for innovation and change? Was it the administration? Were ideas coming from the board? What do you remember about how new ideas worked their way through the system early in your career here?

01-00:41:43
Van Renan:
Actually it would be all three parts. Typically what you saw was at the physician level is you began to have conversations about what are new services that we need to go through the rigor to analyze. Do we have enough patients to support the new service? [42:00] What are the different technologies that we would need to put into place? Are there other caregivers or other medical specialties that we might need to bring in to move in a new direction? Once you kind of got to a place where you began to then have those conversations with medical staff, senior leadership became involved. Then ultimately taking those that cleared those two levels to the board for further conversation. It was more evolutionary as you began to add different elements to what Mary Washington Hospital was offering to the community at that time.

01-00:42:46
Rigelhaupt:
As you describe it, it is certainly what I’ve learned in terms of researching this project, hospitals are run by physicians, the administration, and the board. There’s a kind of three legged stool.

01-00:42:58
Van Renan:
Yes.

01-00:42:59
Rigelhaupt:
What do you remember about the dynamics between those three different groups? Was there a certain synergy? Were there places where there were disagreements? That first year you were here, how did the board and physicians and the administration work together?

01-00:43:18
Van Renan:
Certainly was a great enthusiasm at the time because they had been in the new facility for only a couple of years. The cardiac surgery program was just in its infancy and so there was a lot of energy at all the different levels about a new era for Mary Washington Hospital. Invariably there’s healthy debate, but one of the things that I certainly remember is all the different elements were very patient centered. At the end of the day, what was right for the patient? What was right for the community? That kind of guiding principle helped to coalesce any disagreements that might evolve. To the organization’s credit, it went back to the question of values and culture. This kind of commitment to, at the end of the day, what is right for the patient and what is right for the community? If we do that we’re going to be okay.

01-00:44:34
Rigelhaupt:
Do any of the debates that you described as healthy debate, in the first year or two you were here, stand out in your mind? Where there was some debate about directions between the board, and physicians and the administration?

01-00:44:47
Van Renan:
In the early days, probably not so much. We had lots of capacity at the time. We were still trying to grow into those 327 licensed beds. [45:00] I certainly remember my first winter at Mary Washington Hospital. I distinctly remember in my interview—because coming from Nebraska, typically we would have long cold winters. One of the questions I asked was, “What are the winters like in Fredericksburg?” The director of human resources at that time said, “Oh, it hardly ever snows here and if it does it’s gone by noontime.” Well, my first winter in Fredericksburg was December of ‘95 into ‘96 and we had two nor’easters back-to-back that dropped about thirty-six inches of snow in the first two snowfalls. I don’t remember thirty-six inches of snow in Lincoln, Nebraska in a lifetime. When the census got to maybe the upper 200s there would be a buzz in the building. The building would almost shake. The Mary Washington of today, we’re in the middle of summer now and our midweek census will be about 350 and we’ll get into the 400s as we get into wintertime. It’s a very kind of different demand. The conversations and the different perspectives began to emerge as you kind of get farther out and where you got closer and closer to your bed capacity. How were you going to care for patients when you run out of beds? That started the conversations around the 100 bed expansion and what did that need to look like. Where we would do the building? What were the different nursing care units that needed to have some extra attention to it? Probably the next big one after that actually was the debate around do we build another 100 beds at Mary Washington or do we look at building a new hospital someplace either in Stafford or some surrounding region? What was the best thing that we needed to do as a health system to continue to do a good job of caring for our community?

01-00:47:43
Rigelhaupt:
And that story of expansion is really important and I’ll continue to come back to that. But the other thing I wanted to ask about in terms of the early years you were here is the nursing program. While you came into the health system as director of the cardiac program, undoubtedly your experience as an RN, you were attuned to the nursing program. [48:00] And I think, as you described, it’s incredibly important for cardiac patients, the continuum of care. What did you see as some of the strengths of the nursing program? Both nurses directly working in cardiac care, but if you could speak in general terms that you saw throughout the hospital when you started here.

01-00:48:28
Van Renan:
There was a great enthusiasm because it was new patient care responsibilities for nursing and there were opportunities for new education and professional growth. That was exciting to watch and to be a part of. It was also a great recruitment tool. You had nurses that before, the only place they could go to work was either in DC, Charlottesville, or down to Richmond to get that kind of patient care experience. To be able now to come to Fredericksburg was an exciting opportunity. Certainly the challenges of getting around and commuting to either one of those three areas continues to be a great challenge. Fredericksburg and Mary Washington Hospital provided a wonderful work experience that really brought some top-flight nurses from around the state and region to come to this location.

01-00:49:41
Rigelhaupt:
I imagine you coming into the cardiac program and expanding it and then you bringing in nurses with higher levels of education, certificates, knowledge, and in some ways changing the level of nursing care within the health system. Did that present any challenges, or was that something that was really well supported by the organization?

01-00:50:08
Van Renan:
Very well supported by the organization, and it was important for us early on to provide a learning opportunity for the people that brought you to the dance. For the nurses that were part of cardiovascular care and the health system at that time, we were providing them the educational opportunities to help elevate the level of care that they provided and to help prepare them for maybe some new career direction. It was promoting retention within the nursing ranks and so it wasn’t just about bringing in new people. Certainly there were people that were attracted to a new opportunity, just like I was attracted to come halfway across the country to a new kind of unique work environment and work opportunity. [51:00] There were people that had helped bring you to that place in your evolution and in your care history that earned the opportunity to get that special education as well.

01-00:51:20
Rigelhaupt:
Do you recall the organization making an effort to enhance the nursing program in general? Not necessarily directly in ICU, post-operative, post-op cardiac care, but just in general medical-surgical floors? Something like the cardiac program and the change to a regional medical center meant you had patients with a higher acuity.

01-00:51:49
Van Renan:
Yes.

01-00:51:51
Rigelhaupt:
Do you recall the organization supporting enhancements for nursing education throughout to deal with higher acuity patients?

01-00:52:01
Van Renan:
I think one of the things that really began to take off at that time from a nursing perspective was the organization actively recruited clinical specialists. These were advanced degree nurses. They were all master’s prepared. They had special credentialing and experience in particular groups. Certainly with the cardiovascular program, it was important to have those clinical specialists as part of the nursing staff and to prepare all the nurses involved in cardiovascular care. You began to also see that branch out into our general med-surg units, women’s and children’s areas, and so those became the early educators. They were out there assessing where we were at from an education perspective. What were new opportunities for learning? They were helping to put together those lesson plans and conducting all the various educational offerings. What were the skills or events that we needed to have on a regular basis to keep people at a particular level? That was one of the critical elements in the nursing care evolution starting in that ‘94, ‘95 timeframe and certainly has carried forward to today.

01-00:53:35
Rigelhaupt:
So this is certainly an era, in which, as you describe, the nurses have a higher level of education, clinical expertise. And I imagine this was an era in which they’re bringing their expertise to the administration and the physicians. But there’s a long history of a kind of hierarchy between physicians and nurses. [54:00] And I think by the 1990s it’s certainly breaking down, but I’d be hard pressed to say it’s gone and certainly, I’m sure, there were some older physicians that still had grown up with a different model and dynamic. What was the reception like within the organization to the expertise for nurses and bringing ideas for clinical practices, to changes within the organization?

01-00:54:23
Van Renan:
I’ll give credit again back to Dr. Armitage. The relationship that he fostered with the nurses involved in patient care and with his Pittsburgh experience was much more collaborative. There was a conversation. He knew that those nurses were his eyes and ears to the patient around the clock and he knew implicitly that they were the ones that were implementing the things that needed to take place. That became a model of care for others. As new physicians joined the medical staff, they were coming from the big academic centers and larger programs where you were beginning to see this change in the relationship and that has carried forward today. At the end of the day if there’s still a question, the physician is ultimately responsible. Once in a while they have to be the tiebreaker in a conversation, but it’s very much a dialogue that goes on back and forth. I’ve enjoyed immensely being a part of that and seeing how that has changed from my early days in the ‘70s, that relationship between nursing and the medical staff to what it is now. The advanced education. Entry level now, nurses are coming out with their bachelor’s degrees. Many are going on to their master’s for specialization. You’re seeing many now transition to Ph.D. in nursing. That has been exciting to watch. As the body of nursing has changed over time and how the complexity of patient care has changed over time, it demanded education to evolve. Specialized nursing education evolves to be able to meet this kind of changing patient care dynamic.

01-00:56:47
Rigelhaupt:
I know it’s not easy to probably pinpoint an exact year, but where do you feel like the organization was those first few years you were here in that transition to a much more team-oriented approach, as you described in the cardiac program? [57:00] It sounds the cardiac program, Dr. Armitage emphasized that from the beginning and it started that way. But in other things you saw within the hospital—was that well underway when you started here or was that a transition that built on the success of the cardiac program?

01-00:57:20
Van Renan:
I think it was well on its way. One of the things that really stood out in those early days for me was how young the medical staff was. Many of those physicians, we have grown up together over the last nineteen years. They were coming out of their education programs and early medical experience and were used to this different dynamic. I think that’s one of the things that helped the health system and the hospital to be very successful in this transition time: you’ve got this young, dynamic medical staff and a very engaged nursing workforce working together and they were having healthy conversations. Back to that, “What’s in the best interest of our patient?” That’s the one thing that they agree on implicitly and so it’s dialogue going back and forth to say, “Here’s what’s going on and here’s what we need to do to take care of our patient or a family member.” They were getting questions and things answered.

01-00:58:48
Rigelhaupt:
So one more question before going to the cardiac, some more specific questions about the cardiac program. Thinking about even during the interview process and even early in the first few months, the year that you were here. Although this is a not-for-profit hospital, finances and revenue are important to a hospital. What do you remember learning about Mary Washington Hospital and MediCorp’s finances at the time when you started? Is that something that was talked about during the interview and when you started here?

01-00:59:23
Van Renan:
Certainly you want to make sure if you’re moving your family halfway across the country, that there is a strong financial underpinning. That the health system is healthy and it has an ability to grow and adapt. It was answered implicitly when I described that first day, turning off of Route 1 onto Hospital Drive. You see how beautiful the new hospital was and the commitment that the board of trustees had made and their vision for the community. [01:00:00] You understood that they were going to do everything humanly possible to make sure that they had the right resources to help do an exquisite job of caring for the community. They have continued in that journey. 2013 was the twentieth anniversary of the move from the Fall Hill site to our current site. I was able to reconnect with a lot of the early community leaders, members of the board of trustees at that time, medical staff, and to talk to them about the Mary Washington of today. It has been very satisfying for me to see their vision come to fruition and to see their great wisdom. I wasn’t in the community at the time, but as I understand there was a lot of debate and disagreement in the community. Did we need to build a new hospital? Yes or no? If yes, how big? You kind of roll back to the late-‘80s into the early-‘90s: there was a belief that hospitals and acute care hospital beds were going to be going away and care was going to be done entirely different. There was a certain portion of the community that thought, “I’m not sure we need to build a new hospital. But if we are it needs to be a lot smaller than 327 beds. We don’t need to make this kind of commitment.” The board of trustees and the medical staff were in that conversation. As they kind of begin to envision how this community was going to change and how care might change, they tried to set a framework that allowed opportunities for the next generations of leaders. They believed it would change dramatically and that you always had opportunities to make those changes. Within five years of moving into the new facility, they had to rebuild their entire emergency department and double its capacity. Another five years after that, they had to add a 100 bed tower and essentially double the size of our ICUs. And so looking back now, you really see the great wisdom and the courage that it took as health care leaders at that time and community leaders at that time to say, “This is the right thing to do for Fredericksburg.” [01:03:00]

01-01:03:08
Rigelhaupt:
That expansion and the vision that you described and the discussions in the late ‘80s and early ‘90s, and obviously you weren’t here for that. But when you started did you hear about—were there certain board members that were the strongest advocates? Were the ideas coming from the administration that really advocated to build the physical foundation for what the health care organization is now able to provide?

01-01:03:36
Van Renan:
It would be kind of secondhand information and it would be conversation with individuals that were here at the time, but the board really believed that this community was going to be growing. I believe Mayor Davies was the mayor during that timeframe and certainly he felt, and other community leaders felt, that Fredericksburg was going to continue to grow. We would see some type of out migration from the DC beltway area towards Fredericksburg. New businesses and things would grow. That one of the real attractions in bringing new people to this community: having a very robust and state of the art health care system. That was going to be critical to that growth. Certainly history I think has borne itself out. They were spot on. They knew what it was going to take to keep pace with the community. I think if you challenged them today, many of them would say Mary Washington and the health system today is probably a little bigger and grander and more complex than they envisioned. However, they set a framework in place. If it went farther and needed to go farther than they anticipated, there were ways for it to continue to grow and evolve. The fact is that they had like a ninety-three acre campus for this new hospital, a state-of-the-art hospital. I would hazard to guess there were a lot of people in the community saying, “Why do you need ninety-three acres?” Today, if you drove our campus, it looks radically different from my first day of joining the health system. Just about every lot on this campus is built out. [01:06:00] Again, back to this vision and how it’s played itself out: you see what incredible wisdom and courage it took by the community leaders, health system leaders, and medical staff to set this framework and this evolutionary process in place.

01-01:06:21
Rigelhaupt:
So let me switch gears a little bit back to the cardiac program and ask you about the longer term goals when you first started. As you described, many of the things that needed to happen are multiyear. What were some of your long-term goals for the cardiac program when you first began?

01-01:06:49
Van Renan:
In the first few years it was getting the right infrastructure in place so that the care that we were providing was state of the art and we were getting state of the art outcomes. Also in that timeframe, you began to see how care in the cath lab was changing. You went from just doing diagnostic cardiac catheterizations and began to then introduce balloon angioplasty, where you began to go into blocked areas and try to expand that area to allow flow. Cardiac stents began to be offered. There were new implantable defibrillators. You saw our cardiac valve surgery program. That was the next evolutionary step for the cardiac surgery program. You wanted to continue to evolve with here’s how cardiovascular care is being changed across the country and how it’s being offered at top-flight tertiary level centers. You began to reposition yourself. It was getting the right technology. As cardiologists or new physicians came, they were coming with that experience and so they were bringing a new experience. Then it’s getting your caregiver team the right supplies. If there are any new technologies that you needed to add to be able to continue to grow. When I first started we had two cardiac catheterization laboratories. Today there are three and we have an electrophysiology laboratory, as well, that’s devoted to complex electrophysiology care. [01:09:00] All the special defibrillators, ablation devices—the types of patients and kind of the breadth and scope of the services that you offer has really changed dramatically over the last nineteen years.

01-01:09:18
Rigelhaupt:
What were some of the technologies that you brought in in your first few years that really were a big part of the cardiac program?

01-01:09:32
Van Renan:
Certainly Dr. Armitage’s team, they were helping guide what we needed to bring from a surgical perspective. One of the things would be introducing balloon pumping. That was a way to help patients whose hearts were not quite functioning ideally. It was to be able to support them, either to prepare them for surgery and get them stabilized or if we needed to have some stabilization after surgery. The cath lab—what was offered in our interventional cardiology programs was changing dramatically because the new stents and different types of devices that were being introduced. That was a very large evolutionary timeframe. Then patients were sicker. There were ways to keep you out of the hospital, but once you finally got here the acuity was different. It required the ICU types of supports and other care environments. It was a change so that you are used to caring for a more complex, more acute patient. The types of patients when I started my health care experience that might have been up in a patient bed, today they would never be admitted. That entry point that brings you into the hospital is radically different over my almost forty years of hospital based care experience.

01-01:11:34
Rigelhaupt:
Those first couple of years as you brought in your technologies in terms of what you were able to do with the cab labs, did you have to change the physical space of operating rooms? Was that part of the expansion in your early time here?

01-01:11:53
Van Renan:
They had the framework in place. It goes back to the great vision of the board of trustees and health system leadership at that time. [01:12:00] They got the right building blocks into place and allowed you to kind of go in some new directions. The first big evolutionary or space change would have been the addition of that third cardiac catheterization laboratory. There were lots of logistics in trying to create some additional space in and adjacent to the cardiac catheterization laboratories that allowed them to expand. There was the introduction of a freestanding electrophysiology laboratory. In the original design of the hospital, when they moved in in ‘93, there were three distinct ICU pods that were physically separate from each other. There was a medical ICU, there was a cardiac ICU, and there was a surgical ICU. With the 2004 100 bed expansion, we were able to bring the ICUs together, expand their bed capacities, the size of the rooms, and still have one of those original pods left over that allowed us to move into that vacated space to build out the electrophysiology laboratory. That became kind of a pre-procedure, post-procedure staging area for the cath lab patients. It helped from an efficiency perspective. You were able to see more patients in a given day than you did in the old systems. There were ten original ORs in the original build out. We’re at fourteen now. The size of an OR, the space needs, is very different from the original design. Unfortunately, you’ve got kind of a fixed shell and so that precipitated very creative space solutions that allowed us to expand the footprint to introduce four new ORs and to right size them for contemporary operative care. We have a freestanding outpatient surgery center that’s physically adjacent to Mary Washington Hospital. A lot of those early, ‘93, ‘95, surgical cases, they’re actually all done on an outpatient basis in a free standing outpatient environment. [01:15:00] The intensity, the space needs, and the technological supports that go into that hospital based OR today, are very, very different. One of our greatest challenges has been just keeping up with this changing demand.

01-01:15:23
Rigelhaupt:
Could you walk me through the process of building out an OR, as you described the electrophysiology lab? Did that happen while you were still director of the cardiac program or had you moved into a newer position?

01-01:15:38
Van Renan:
I had received a promotion, my first kind of really big promotion in the health system, actually to an executive level position. I had about half the clinical house responsibility. Those big expansions probably came in that timeframe. I still had an opportunity to be very involved in the planning discussions. I use the analogy of moving boxes in your garage. You move one box and typically that precipitates the need to move another box and another box. It was sitting down with your physicians, your planning team, and your clinical staff to say, “What is the need? What is the size of the footprint? What are our options?” In those options, were there any boxes that we would have to move along the way to be able to accommodate that need? Back to the electrophysiology laboratory: we couldn’t build that out until we had that ICU pod freed up and that meant that was all part of the planning and thought process of to the hundred bed tower. How should those ICUs be laid out? Instead of having three separate ICUs with no physical connection other than having to go out into a main corridor or down a hallway and back in another door, was there a way to construct that so there was a physical flow in those ICUs? If today I need more medical ICU type beds I had a way to flow. If I needed more surgical ICU beds or cardiac beds, I had a way to make that flow and to be able to move staff back and forth and to move technology and support back and forth. There are lots of logistic discussions and details and planning that goes into bringing that together. [01:18:00] On the OR side, oftentimes it meant displacing things that you had built out before. So you had to go move that, replicate it someplace else to allow you to be able to expand various footprints while still maintaining the flow and the efficiency that you want to keep in place in your ORs. Then as the complexity, the different types of supports, and the technologies that you might bring into a particular surgical case, that meant expanding the size of the room footprint. Sometimes that meant the only expansion point was into the core. Originally the ten ORs were in a track setup. You had a support core in the middle of that. You had various supplies and things that you kept in place so that you could go in and out of rooms, into a sterile environment to bring in new supplies or equipment. If that’s the only expansion point, then how do you replicate that in an efficient manner for all that storage and to have ready access to it? That created some logistical challenges as well. It’s been a great problem to have. There is enough need and growth in the community and in the health system that you have to go back in a relatively short period of time, over twenty years, and to make those substantive changes. A lot of people would like to have that kind of problem.

01-01:19:51
Rigelhaupt:
One of the things that’s fascinating about something like an OR expansion and movement, the growth, is all of the different perspectives that are brought to it. You have physicians in a clinical perspective. You have nurses in a clinical perspective. You have occupational engineers. You have administrators. What are some of the things you remember about the problem solving? And I don’t mean that in a negative, problem solving, but how do we expand is a problem you were facing. What do you remember about those different voices and how they interacted in terms of solving those problems and the different perspectives they brought?

01-01:20:28
Van Renan:
Certainly there were a lot of group meetings. You needed all those different perspectives at a table at the same time because as somebody might bring up an idea and somebody else who saw that beach ball from a different angle brought up a new question. Ultimately it seemed like it took a little bit more time, but the end product was typically better. [01:21:00 ] The size and the types of technologies that you needed to support changed, it affected all the other infrastructures—what were all the different kinds of electrical feeds, the cooling and heating systems, and water? That all had to change and evolve, as well, because it just put more and more load on the system. Then our emergency power systems had to evolve because now you had more and more mission critical, high-energy demand technologies and care environments that needed to run whether the lights are on or whether the lights are off. It took a lot of thought and planning and preparation. Getting those right pieces in place allowed you to meet that changing demand.

01-01:21:59
Rigelhaupt:
Who were some of the people most involved in terms of the physical planning, the engineering side, in terms of making sure there’s backup power and your water, different HVAC units for ORs?

01-01:22:08
Van Renan:
We would always have at the table one of the senior members of our engineering staff. They are the content experts that really understand the infrastructure, whether it be power, water, heating, or cooling. Let’s say we’re bringing in a new cath lab. You’re bringing in content experts from maybe a Siemens, one of the providers. They’re bringing their engineers and saying, “With this new imaging system, here are the electrical demands, here’s the heat load that it puts off, and here’s the cooling demands.” Were there any special types of plumbing that needed to go into place? You have got medical staffing and caregivers at the table. They understand the flow, the patient flow, and the room flow that we need to take place. They are providing a perspective of how things are positioned. Do tables need to go this direction, lengthwise across a room? Everyone is bringing that kind of unique experience and perspective to the challenge to make sure that at the end date, when you cut that ribbon and you open, you know it’s going to work and it’s going to work well.

01-01:23:42
Rigelhaupt:
Did you find yourself during these planning stages of an incredibly complex physical space drawing on your multiple backgrounds in terms of having been a nurse, a respiratory therapist, an MBA? Going back to being an engineer? [01:24:00] Did you find yourself drawing on your education to deal with very multidisciplinary problems?

01-01:24:09
Van Renan:
I think it quite helped me during that time and certainly is used extremely well today. I may not be the content expert in any of those disciplines, but I have a foundational knowledge and I understand the terms and the science for each of those. It’s helped me lead conversations. It’s helped me identify content experts to be able to pull these different disparate pieces together.

01-01:24:50
Rigelhaupt:
So I see in the organization’s milestones, 1998, the one thousandth open heart surgery performed. In four years, a thousand open heart surgeries. What does that number represent?

01:25:07
Van Renan:
It’s a thousand patients, people in our communities, and a thousand families that you have been part of their health care journey. You helped them through a very difficult and frightening time in their life. One of the things that you enjoy, especially as a nurse—and I’ve had some opportunity to work and be part of the cardiac rehab process—is to have, in my experience, been able to see patients go across this continuum and be able to see them on a treadmill or exercise bike or even better yet they’re in your church. You see them in the grocery store or out shopping and they remember what you’ve done for them. To see them kind of get back to a state of health and you have helped them reintroduce themselves back to the community. That’s why you do what we do in health care. It’s about helping people in these challenging times and getting them to a place where they can get back to the families, get back to their life, and to their community. That’s what it’s all about.

01-01:26:40
Rigelhaupt:
Thinking back to when you started in 1995. Correct me if I’m wrong. My guess is you didn’t have some target number, that by this date we’re going to have done this number of procedures. Was it a reasonable pace of growth? [01:27:00] Was it fast? Did you think you would be at a thousand open heart procedures three years after you started here?

01-01:27:09
Van Renan:
I thought it was a reasonable milestone. We didn’t go and say, “By such and such date we’ll be celebrating our one thousandth open heart.” Certainly the experience that I brought from Lincoln, Nebraska, and then beginning to understand the demographic of our community and where we were drawing patients from, you would have predicted in that 250 to 300 patient number over that span of time. Now, our community has continued to grow and so you’ve got potentially more patients that can be seen in your cardiac surgery program. However, also in that time, there has been a different evolution. I talked about all the things that are going on in the cardiac catheterization laboratories. There are interventions that are taking place. Before those folks would have gone right to cardiac surgery and we’re beginning to take patients out of cardiac surgery. With evolution and the introduction of new statins and preventive care, it’s helping patients hopefully prevent cardiovascular disease. Or if they do begin to develop cardiovascular disease, it’s not evolving as quickly and sending them into environments where they need a direct intervention. You’ve got a couple countervailing forces that has kind of kept the number of patients that we’re doing in that 300, maybe as high as 350, range. I think that kind of evolutionary work will continue. There will be new things that you’ll see go on in the cath lab. From a patient perspective and I would put myself there, I am getting to that place in my life where I could be at patient sometime. We would all choose something other than surgery if we got an equal outcome and that’s the right thing to do for patient care. If there’s something that I can be doing that helps keep me out of the cardiac catheterization laboratory—me as a patient and certainly my family—I’ll be doing those kinds of things. It’s that kind of balance we need to be able to continue to provide and so we talked a lot about kind of cardiac surgery. [01:30:00] The evolution of the whole cardiovascular program—I’ll do kind of broad groupings. We talked about cardiac surgery. The evolution and growth in what went on in the cath lab and the evolution and growth that you saw in preventive and pre-procedure care. Then on the post-procedure care: once we’ve got you through an event, what are those things that we can help you be doing and the types of care that we can provide to keep you from coming back? So that you’re not coming back for the second surgery. You’re not coming back for the second cardiac catheterization or intervention procedure.

01-01:30:51
Rigelhaupt:
Was prevention something that was emphasized in the cardiac program from the beginning? Is that something that came along with a new surgical subspecialty that you could provide in terms of community health care? New expertise in terms of preventative ideas?

01-01:31:10
Van Renan:
Certainly I saw it when I joined in ‘95. I think it is just foundational to medicine and you could back up decades, decades and decades of medicine and medical training. Physicians are trained. First and foremost, you want prevention. What are those things I could do to help you remain healthy? What keeps you out of a hospital and keeps you from needing special care? That framework was in place, very robust, and was part and parcel to the physicians that were here at that time and have come since. I know it’s an important part. If you look at the medical schools at VCU, at the University of Virginia: that’s all part of the foundation that they put into each new physician that they graduate. There are new medicines and things. We talked a lot about buildings and technologies. Medicines have changed. Things that helped lower cholesterol in patients when you thought it was going to be impossible to lower their cholesterol. There are other medications. Getting patients identified early on in the disease process, getting them started, making sure that they are taking those medications faithfully, that they’re making the adjustments in the personal lifestyle, making the right lifestyle choices, whether it be sensible exercise, don’t smoke, drink sensibly—getting those foundational things in place. [01:33:00] You do those, you’re going to do a very good job at making sure that patient doesn’t need extra complex care.

01-01:33:09
Rigelhaupt:
I’m testing here. But, in general, hospitals are acute care centers. There is not always an emphasis on prevention, not always an emphasis on public health. And it sounds like from when you started here, that the cardiac program in particular really was emphasizing a lot of preventative medicine.

01-01:33:34
Van Renan:
Even looking back to the mission of the health system at that time: core to that was improving the health status of our community. It didn’t say only through hospitalization or complex care. Improving the health status is a very, very broad descriptor. Back to that, it is the important connection to the community and making sure that we’re well positioned. We need to have willingness and an ability to embrace all aspects of improving the health status of the community, from an integrity perspective and from a caregiver’s perspective. Doing that in the least invasive and least resource intensive way is the right thing. That is what you would want to happen to you as a patient. That’s what you would want to happen to your family. That has been core, certainly in my nineteen years at the health system. The whole philosophy around care and prevention is part of the fabric of medical care in the community.

01-01:34:51
Rigelhaupt:
So thinking about the cardiac program in terms of prevention. Was that also then one of the benefits to the community in the sense that not only did you have the potential for open heart surgery, higher tech, higher skilled procedures. Did new treatments, be it statins or preventative medicine in terms of cardiac care, come to the community faster because there was a higher level of expertise and a cardiac program? Did they make it out to cardiologists in the community at a different rate that might not have happened without having the cardiac program at the hospital?

01-01:35:37
Van Renan:
I think the messages were reinforcing each other and they were consistent. Starting with my primary care physician and the individual that was responsible for caring for me on a day-to-day basis, they were hearing those same kinds of prevention medicines. Now you’ve got all these new cardiologists and many of them with different areas of sub-specialization. [01:36:00] They were reinforcing the message that you just heard from your primary care physician. Now you add cardiac surgeons and other kinds of critical care medicine specialists reinforcing the same message. And so it starts with prevention. We have added new resources. If something doesn’t work, we can care for you in the continuum, but first and foremost we want you to stay well.

01-01:36:40
Rigelhaupt:
Are there ways that the cardiac program supported the communication of new ideas between physicians? And part of what I’m asking about is from when I interviewed Dr. Ryan. When he started here, I think he says about seventy physicians, and not only did you know all the physicians, you knew their wives and children’s names. And he said wife because it was largely men when he started. But I think it’s over 600 physicians on staff now. It’s a little harder to have that level of communication. In terms of the new ideas of medicine, either be it about prevention or be it about new procedures, how did the cardiac program try and play a role in communicating new ideas and new evidence-based medicine between physicians?

01-01:37:33
Van Renan:
Part of the attraction for me, and the program really was still in its infancy at the time, was you had at the same table cardiologists, anesthesia, and you had cardiac surgery. You had kind of this multidisciplinary approach in the planning and in the conversations. There was a conversation back to primary care. So when I started, primary care physicians were still seeing their own patients and rounding on their own patients in the hospital. That has changed over nineteen years to where you don’t see that very often. You have hospitalists today that are doing the day-to-day patient care on behalf of the primary care physicians who are still back in their office trying to see more patients. Hospitalists specialize in acute care and hospital care. But you had this dialogue between the different elements and the people that frequented the hospital at that time. [01:39:00] It was still the same core and so there was a daily opportunity for them to interconnect. It might be in the medical staff lounge or it might be up while seeing patients, but there was a dialogue for them to keep in touch with each other. Today with six hundred physicians on the medical staff, many of which don’t come to the hospital—they’re outpatient based and communication is more challenging. The core group still has that opportunity in the daily flow and milieu to stay connected to each other and to exchange ideas back and forth. You try to look for educational opportunities. One of the things that we’ve done over the last say, five years, is on the cardiovascular side. We have an annual symposium. It’s an educational symposium that creates an opportunity for community based physicians, all the various specialists involved in cardiovascular care, to get together and to hear educational talks. We’ll oftentimes bring in outside experts and there might be a particular theme that we’re focused on. Something unique we’ve done over the last few years is to identify some patients that went through a full continuum. You were able to kind of follow those conversations and changing patient need over that timeframe who brought in different disciplines. It’s starting with the primary care side and the assessment and the prevention, and if that didn’t go well, and you brought him to cardiology. Then maybe it went to the cath lab. Maybe the patient then transitioned to surgery, then to rehabilitation. You were able to trace that patient’s entire experience over some span of time and have the conversations go back and forth. Those have been really enjoyable because many times physicians know that particular case you are talking about and so they can reflect on the time. They can remember the time, some of the conversations, and some of the challenges. There’s this rich dialogue that comes out of that.

01-01:41:45
Rigelhaupt:
So you started, the cardiac program’s in its infancy, it’s new. Was part of your job as director to publicize the new cardiac surgery and the cardiac program opportunities at the hospital?

01-01:42:00
Van Renan:
You would certainly be working with our marketing/public relations department at that time to try to keep the community abreast of kind of what were either new services—new things that we were beginning to offer—and keeping them attuned to what was the growth of the program. We were looking for opportunities to get feedback on were there changes that we needed to make, not so much the care, but flow. How do we make it more patient friendly and more family friendly? It was a lot of work and discussion on getting feedback. Were you prepared? When you left the hospital did you feel prepared to be able to continue your care at home? It’s looking to keep the community involved, attuned to where the program was going, and looking for new opportunities for it to improve upon itself. That was a very important part of the early days of the program. One of the first things I did in my first year was to celebrate the first anniversary. They had just completed a renovation on a portion of the Fall Hill Avenue, the old Mary Washington Hospital. We held our first anniversary there and invited all the cardiac surgery patients and other cardiovascular patients that we had cared for in that first year. We invited them, physicians, and their families, to come over to Fall Hill and spend a Saturday together. It was an incredible experience. We’re planning for the twentieth anniversary of the cardiac surgery program, to go back and look at those pictures again. We kept them all. We will look back and to see those faces and how some of our hair is certainly going to be very different. For me this will be very similar to the joy I got out of helping the original board members and community leaders celebrate the twentieth anniversary of the move here. To see their vision; it came together. I’ll get that same kind of enjoyment and experience in seeing the physicians and caregivers who have been part of this journey and who were part of that first visioning group. To be able to see twenty years of how this program has grown and flourished over that time. [01:45:00] It’s going to be exciting to me and I look forward to November 8th this year, to the twentieth anniversary celebration.

01-01:45:18
Rigelhaupt:
Twenty years later will be a very different story. But in those first couple of years, it’s just a new program. What do you remember about talking with the marketing department and thinking about as director of a program? How do you tell the story of a new cardiac program at Mary Washington Hospital?

01-01:45:39
Van Renan:
They certainly were very excited. They were part of that enthusiasm that was across the health system. Here’s something very special that the health system is offering to our community. They were reaching out. We certainly had prior experience in framing that message. At the end of the day, the community needs to be able to understand and it needs to be in terms that they understand. We were helping them understand that we offer this. You don’t have to go someplace else to get this service. We have specialists here today. Here’s where they received their medical education. Here’s their training. These are top flight physicians. You don’t have to go someplace else to get this level of expertise and technology. You can get that here at home. It’s important to us as a health system to be able to offer that level of service to you without leaving the community.

01-01:46:47
Rigelhaupt:
As a new program and an incredibly high tech program, and very real change from what had been in terms of having to leave to go to say Richmond or Charlottesville or the DC area in terms of cardiac surgery. By the time you got here in 1995, was there any skepticism about having open heart surgery at Mary Washington? This was a new program, and was a significant change from what had been here. Did you sense that there was any skepticism in the community?

01-01:47:35
Van Renan:
I didn’t sense any type of skepticism. You’re going to find somebody that will only go to the Cleveland Clinic or Mayo Clinic to get even simple care, but the vast majority of the community and medical staff embraced it. Certainly Dr. Armitage and the team did a lot of work and preparation. They were cautious and methodical in the patients that were selected and that you were building on your success. [01:48:00] They had been going now for eight, nine months prior to me starting in the health system. It built on the confidence. You demonstrated success. They were seeing those community members back at church: “I know Ed. He had open heart surgery at Mary Washington. Dr. Armitage. That’s him over there in the second pew.” Or I see them out to eat. You see them now and they are at a place where they’ve returned to a sense of normalcy and a life. That just built on the community enthusiasm. I think that also pushed the community to ask more questions about, “Okay, where do you go after cardiac? What are the other things that you begin to add and build on? I’m still having to drive someplace to get this. What is it going to take for us to be able to do this here?” If you’ve ever been a patient or you’ve had a family member who has been a patient for an extended period of time, it helps to be able to stay in your own community in familiar surroundings and see physicians and other folks that you’re used to seeing. It’s a stressful time. So that’s all part of kind of the healing process. Providing that very community-oriented framework helps with care. To have to go someplace fifty, sixty miles away, and then have my family try to go back and forth, just made something that much more difficult.

01-01:50:05
Rigelhaupt:
I think we’re just about at noon. Can I do one more question for today?

01:50:09
Van Renan:
Sure.

01-01:50:11
Rigelhaupt:
Can you think back in the first year or so, did you get a sense of the model that the cardiac program was building in terms of a higher level of surgical care, multidisciplinary team? Was it immediately or quickly becoming emulated in other clinical programs within Mary Washington Healthcare? Did you see its processes, even if it’s a different sub-specialty, did you see its processes or team building, beginning to have an effect on other aspects of surgical or any clinical part of the organization?

01-01:50:54
Van Renan:
Physicians to a large extent, by nature, are competitive. [01:51:00] It’s part of what’s driven them to success, whether it’s in the classroom or in their medical careers. One of the things from my perspective was a healthy kind of competition. Everyone kind of kept elevating their games. What used to be the ceiling before was now a little bit different. There were new challenges. It created new conversations and dialogues together. You saw them in those conversations and asking what is it they’re doing? What’s that team doing differently? How can I replicate that in the patients that I’m caring for or in a new service that I might want to offer? So yeah. It set kind of a new standard and people could see how it worked. It’s not a cookie cutter, but they are smart. Physicians are so, so smart. They see the important aspects and how it fits into the puzzle pieces that they have in the patients they’ve got to care for. It just began and continues to build on itself.

01-01:52:30
Rigelhaupt:
One more question. To follow-up on that, as physicians are really trying, and others, be it surgical, other clinical programs, trying to raise the ceiling, as you described. Was the administration ready to have physicians knocking on their door saying, “We want to do X. We want to do Y. We want to push.” And I imagine you, as an administrator, as director of a program, saw senior level administration and worked closely with them. Were they ready for physicians to keep pushing the health care system forward in that not competitive way, but close to it?

01-01:53:14
Van Renan:
Absolutely. It goes back to sitting down with Fred and hearing his kind of vision. You could see how this is going to be part of a natural evolution. Fred had come from the Pittsburgh area, as well, and so he had been down the journey before. He saw how sometimes it’s kind of starting with this one pebble, this one significant pebble and how it might begin to build on itself. Absolutely, the administration and the board of trustees embraced it. It was what they were hoping. [01:54:00] A plan would come out of making this kind of resource commitment to the community that would begin to spur innovation in new directions and that our role in the community would change. More and more patients would be able to stay at home to get care than ever before in the history of the organization.

01-01:54:25
Rigelhaupt:
I think that’s a nice place to stop for today.

01-01:54:26
Van Renan:
Okay.

01-01:54:27
Rigelhaupt:
Thank you.

01-01:54:27
Van Renan:
You bet. I enjoyed it.
[End of interview]

Interview 2
02-00:00:05
Rigelhaupt:
It is October 14, 2014. I’m in Fredericksburg, Virginia doing a second interview with Kevin Van Renan. And I want to start off today by talking about the era from roughly 1995 to 2000, which we didn’t talk about as much in our last interview. And I’m wondering if you could just generally talk about this era of growth and expansion in the organization.

02-00:00:36
Van Renan:
Much of that time was devoted to not only getting to really understand and put the infrastructure into place for a very successful cardiac program, but it was also beginning to help get the word out and to make connections in the community with the referring medical staff about what was now available at Mary Washington Hospital. We were making sure that we were in a position to be able to grow as the community continued to grow. It was a very exciting time for the program, to have that kind of growth and quick notoriety within the region.

02-00:01:23
Rigelhaupt:
Was there a relatively quick—transition is not the right word—but the medical community getting on board with the growth, the physicians in the community.

02-00:01:35
Van Renan:
As you started to experience very positive results and very positive feedback from their patients, it didn’t take long for the local medical staff to really embrace a cardiac surgery program and the team. And they were your best marketers in the community. Certainly, that relationship between your primary care physician or your cardiologist—if they’re giving you advice and saying, “Hey, I have a hundred percent confidence in this team. I’m part of that team. They give wonderful care. They give wonderful service.” It goes a long way towards setting aside any fears that patients or the family may have had.

02-00:02:23
Rigelhaupt:
Do you remember some of the specific ways that you, as an administrator in the cardiac program, the director of the cardiac program, were working with local physicians, and local cardiologists, and primary care physicians?

02-00:02:37
Van Renan:
The physicians, at their core, are scientists. The profession is steeped in science. They love information, they love data, and so an important part of my responsibility was to actually put it in front of them. Here is our quality information. Here are the types of things that we are doing, and the types of outcomes. [03:00] This is how we compare against others in the country. That really helped kind of set the framework for them to have that secondary conversation with their patients and their family members.

02-00:03:17
Rigelhaupt:
Do you remember any instances of physicians being hesitant to embrace a new specialty in terms of cardiac surgery?

02-00:03:26
Van Renan:
I didn’t experience what I would call hesitance. But as the program continued to mature, physicians would continue to kind of ask, “What’s the absolute level of criticalness of the patient? How sick a patient can you care for?” You really had to kind of earn that respect and confidence. Often times, it certainly was our experience and practice to go and index based on acuity. From the inception of the program, we were an active participant and submitter to the Society of Thoracic Surgery national database. That’s the gold standard. They go through and index your patient care based on acuity and based on patient presentation, so that you can get as close to apples to apples comparisons. Certainly, that was part of the information that we looked at and the conversations that we had with physicians in the community.

02-00:04:40
Rigelhaupt:
This year, 1995, second half of the ‘90s, was, an era of growth for the entire organization. What do you remember about the other areas of growth within Mary Washington Healthcare, or MediCorp at the time?

02-00:04:54
Van Renan:
The community was expanding at a very, very rapid pace. Certainly, I remember reading in the newspaper, and there had been a number of articles over that span of time, the rapid growth wasn’t always universally embraced by the community because it certainly put strains on the local infrastructure, whether it be roads or schools. I think one of the great challenges that we had as a health system during that time frame, and into the early part of 2000 and beyond, was just being able to keep pace with this almost seemingly exponential growth that was going on in the region. Making sure you had the right services in place, as new needs began to present themselves. Equally important was that we were offering services at convenient times and convenient locations. [06:00] The organization, up to that point, had been very campus-centric. So, essentially, almost everything that we offered to the community was located on one single medical campus. Parking got to be a real challenge. As the roads became more congested, sometimes, it became very difficult to get to the campus. We really began to take a step back and think about what were those types of services that we might offer in a different location to try and make it that much more convenient for the patients in our community to get care.

02-00:06:40
Rigelhaupt:
You mentioned that the rapid growth created strains more so in the community in terms of infrastructure. Were there any strains within the organization with what sounds like a parallel growth?

00:06:59
Van Renan:
It was beds and buildings that don’t show up overnight. To be able to accommodate that growth, we had to begin to look at the campus infrastructure. Probably in and around that time, we saw the first parking garage for the community show up adjacent to Mary Washington Hospital. You saw new buildings and infrastructure showing up on the ninety-three acre medical campus. The inpatient census, the bed compliment at that time—I think our Certificate of Public Need allowed us to go up to 327 beds and that also includes some of those beds dedicated to obstetric care. You were very limited to the types of services you might be able to offer in that part of the hospital. You began to see more days where all of the beds were filled and you were trying to make room for that next patient who really needed a service. Discussions began at that latter part of the ‘90s and into 2000 about, do we need to look for additional beds at Mary Washington Hospital? And if yes, what were the types of beds and how might you do that construction process? In that growth, within that first few years after 1993 and coming to the new campus and to the new building, we had to, essentially, rebuild our emergency department and double its capacity. It went from an approximately twenty-five room emergency department in the original construction to a new construction project that allowed us to have fifty ER bays that were certainly state of the art, and very, very needed for the care of our community. [09:00]

02-00:09:15
Rigelhaupt:
So, in addition to the space in your need, in terms of both the emergency department and the beds, and the expansion in locations, were there other services or clinical lines that you can recall that the organization emphasized during this period of growth?

02-00:09:33
Van Renan:
As we continue to kind of look at what might be new needs of the community, there were evolutions—I’m not sure I remembered any kind of quantum leap in a particular direction. To be able to care for higher numbers of patients required additional staff, nursing in particular. New members to the medical staff—the medical staff was growing and needing to grow at a rapid pace. In and around the latter part of the ‘90s and into 2000, you began to see a splitting of physicians—we’ll use the term hospitalists that really devoted their time and attention to patient care just at the acute care hospital. Then other members of the medical staff were giving up that part of the medical practice and devoting their time and attention to seeing patients in the office and the outpatient setting. The medical staff needed to grow at a rapid pace as well.

02-00:10:46
Rigelhaupt:
Do you recall seeing any effects from the medical staff splitting and more people staying focused at their offices, and then a growth in hospitalists within the organization?

02-00:10:58
Van Renan:
It created challenges for communication because before that time everyone came to the hospital at some point. That was an opportunity and a common point where you could bring physicians and leadership together to have conversations about patient care, hospital operations, and what’s going on in a community. As you saw this divide begin, it was increasingly challenging because physicians that were active in their office, in the outpatient setting, didn’t have the opportunity to come to the hospital. You had to think of new ways to get people together or to communicate. That challenge continued well into 2000 and up through today because you see that same division. I would predict you probably will never see it go back to the old days where everyone came to the hospital to provide care. [12:00]

02-00:12:09
Rigelhaupt:
So, correct me if I’m wrong, but I imagine from the beginning, with the cardiac surgery program, that divide was in place. Dr. Armitage and his team doing the advanced cardiac surgery and then some of the primary care physicians would not have been as involved with patient care at that level, and so that divide had probably taken place earlier around the cardiac care program. Were there things that you learned in the cardiac program, in terms of communicating with primary care physicians, or even cardiologists that were in the community that were more outpatient-based, that you tried to have be part of the larger organization as this divide was occurring?

02-00:12:56
Van Renan:
Something that I learned in my experience in Lincoln, Nebraska at Bryan Memorial Hospital with their very large heart program was referral relationships are about professional friendships, communication, and trust. Certainly, Dr. Armitage had learned that in his work. We both brought that to the community. From day one Dr. Armitage was very engaged and meticulous to make sure that he personally followed up with referring physicians, whether it be a cardiologist or a primary care physician, to be able to communicate on a one-to-one basis and develop that professional friendship, collegiality, and trust. It was part of the original DNA at the inception of the program.

02-00:13:50
Rigelhaupt:
In terms of the communication, was this primarily phone calls, personal contact, or were there ways that this became institutionalized? And I don’t mean that in a negative way, but that it became a part of a practice?

02-00:14:05
Van Renan:
It was both, either phone calls or personal contact. That was also followed up with written contacts. You made sure that all of the operative notes—his notes about the outcomes of whether a surgical case or whatever care that he was providing at the time—that the primary care physician had it in their hands and was a part of a patient record. He also kept track in his mind that if we happened to see each other in a social setting, or if you were at the hospital, he’d be able to have that one-to-one conversation. That was really, I think, important, certainly at the beginnings of the program, and helped fuel this growing trust and referral to the program for the growth. [15:00]

02-00:15:03
Rigelhaupt:
If I recall correctly that the one thousandth open-heart surgery was in ’98, if I am remembering from our last interview correctly. That’s a relatively—I mean, a lot of surgery in a few years. Did the expansion of the cardiac surgery program present challenges for keeping that communication as it grew, what were some of the ways that the organization really tried to keep up with communication and the contact with physicians not in the hospital?

00:15:38
Van Renan:
It required a great amount of discipline on Dr. Armitage and his team’s part. It’s, I think, a testament to him and the team. There was this commitment to being able to provide that level of personalized service, both to the patient, their family, and the referring physician. They all came from much larger programs than Mary Washington Hospital even after that initial growth. That was part of how they conducted the professional practice in Pennsylvania and certainly were able to maintain that here in Fredericksburg.

02-00:16:24
Rigelhaupt:
As director of the program, do you recall some of the ways that you tried to create the infrastructure and the culture within the cardiac program to support that kind of communication, to make sure that there were opportunities for physicians to talk or to really make sure that trust and communication stayed a core part of the program?

02-00:16:47
Van Renan:
We all, as a team, stayed very connected together. The conversations that we had on a regular basis not only involved looking at how the surface was growing, but also what were the quality safety metrics? Just as much conversation and focus in those planning sessions were about who you were getting patients from. It was making sure that we closed the loop. I had an opportunity to talk to referring physicians, cardiologists, and to be able to go back, validate, and ask are you receiving the information that you need? Is there something new that would be helpful to you? Is it timely? Is it accurate? And so it became kind of a feedback loop for us, but it was just part of how we conducted our work from day one.

02-00:18:00
Rigelhaupt:
Are there other important milestones you would point to in this era, from the second half of the 1990s, in terms of other programs within the organization that standout in your mind?

02-00:18:10
Van Renan:
I think in our last conversation—one, it set kind of a new bar for the medical staff to say we have the commitment and the abilities in this medical community to do some incredible things for our patients that they may have had to drive to D.C., or to Charlottesville, or to Richmond for in the past. I think it permitted the medical staff and challenged them to keep looking for new opportunities well beyond their cardiac program. Also, at that latter part of the ‘90s you began to see new things offered in the cath lab: new stenting technology, and drug-eluding stents that began to take, actually, some business away. The cath lab helped patients that would have typically ended up in your cardiac surgery program at some point. At the very least, it began to postpone that surgery. You had to begin to deal with, what is going to be the future of cardiac surgery? Are we going to see a leveling off? But I would offer, also, your ability to care for even sicker and sicker patients in your cardiac surgery program began to inch up. Really, it almost began to offset itself going into 2000 and beyond.

02-00:19:59
Rigelhaupt:
Were there instances that the organization drew on the model that you played a key role in, in terms of growing the cardiac program, that you saw in other areas of expansion—I think, Snowden expanded in ’97, neurosurgery starting. Were there things that people came to you and said, “Hey, how did you do this?” Or that you found yourself using—the organization found that the cardiac program became a template, for lack of a better term, that was useful in other areas of expansion?

02-00:20:35
Van Renan:
I mean, you mentioned neurosurgery. It was a wonderful way to kind of look at what did we learn. How did we approach as an organization cardiac surgery? What was the planning that was required? Being able to evaluate, is there a new infrastructure that we may need, or new technologies, whether it be from an imaging perspective, non-invasive testing in the OR? [21:00] I think as you got into 2000, you began to have conversations about trauma. I think one of the things that we learned in that conversation, in those early conversations, was that you were able to ask, “Is there a documented need for trauma in the community?” Certainly, we had, as a health system, been contacted numerous times, actually by the state, to say, “Hey, would you ever consider offering this level of service?” Dr. Armitage had an opportunity and an interest in being in part of those conversations as well. He was very active in looking at: Is there a need? If yes, what was the type of infrastructure that we might need? It was different from the cardiac surgery program. Now it begins to parallel the growth that we’re experiencing. You saw that you needed to actually do a bed expansion to accomplish it. It was putting yourself in a position to offer a trauma service and do it very well. We needed to expand our OR capabilities and the size of the OR suites needed to be able to expand. We needed to expand the size, the capacity, and the types of services that we offer in our critical care environment as well. And so out of that was the planning and the Certificate of Public Need request to the state to build a 100-bed tower. Part of that building project was the expansion of our OR capacity from ten to fourteen operative suites. The four new ones were now sized and had a capacity to do trauma exquisitely well. It involved a complete rebuilding, new flow, size, and capacity of the rooms in our critical care environment. In February of 2004 we opened that new 100-bed tower and then began the conversations at that point to say, “Okay, we have the infrastructure in place.” We were looking back to what we had learned over the years through our cardiac surgery experience and through our neurosurgery experience. What were the other infrastructure needs to begin to offer the trauma service to the community? We were able to accomplish it and become a Level II trauma program in the latter part of 2008. [24:00]

02-00:24:15
Rigelhaupt:
The trauma program, the surgeons that lead it, when they started, they were employees of the hospital?

02-00:24:21
Van Renan:
Yes.

02-00:24:23
Rigelhaupt:
But as you described, trauma is a multi-disciplinary program?

02-00:24:30
Van Renan:
Yes.

02-00:24:31
Rigelhaupt:
I imagine a higher level of anesthesia care, a higher level of lots of different kinds of care. Were there challenges in working with physicians who were part of medical groups, and part of the medical staff, but not hospital employees, to start something like the trauma program?

02-00:24:51
Van Renan:
Certainly, you had to involve them early on in the discussions about do we have the ability? Is there the interest and in particular time of all of the different physician’s specialties to invest in a trauma program? We had the technical abilities: we had the infrastructure from a critical care perspective. We were able to demonstrate with the cardiac surgery program and neurosurgery program the ability to care for very critically ill patients. But trauma isn’t planned; it can be very disruptive to an organization, and physicians in particular, as they care for their patients, whether it be in the office or into the hospital. To have the time to be able to set that work aside and divert their attention to special patient needs. You had to work through all of those elements. The medical staff in the community had to look at what was going to be the impact to their practice. It was an incredible time for us and certainly another milestone for the organization as they tried to do an even better job of providing a very high level of service to the community.

02-00:26:33
Rigelhaupt:
There had to have been some model in the sense of working with, you know, emergency medical physicians to work in the emergency department; that was a part of expanding and building the trauma program. Were there other physician areas or physician groups from different areas of medical practice that you remember being very excited to contribute to the growth of the trauma program?

02-00:27:00
Van Renan:
I would offer, I mean, there’s a challenge. Many of them, through their work experience or through their medical education had opportunities to be at organizations that had trauma programs. There’s a professional challenge and a reward that goes with that. That was also part of the interests and very broad medical specialties across the organization. The medical staff lives and works in the community. They are very invested in Fredericksburg and this region and want to do a wonderful job of providing service to the community over and above the things that they were trained to do in, maybe, their subspecialty. It was being able to connect with other medical colleagues and care for even more complex patient populations. Being parts of teams means a great deal to them.

02-00:28:20
Rigelhaupt:
So, thinking about—jumping backward in time, and going back to that second half of the ‘90s. By the year 2000, I think it’s pretty clear to say that Mary Washington Hospital is a tertiary care hospital, and has really clearly transformed itself from a community hospital to a tertiary care hospital. And in that context, what I’m trying to ask about is, going backward to your interview here, and that last hour that you said you spent with Fred Rankin, and really learning about the values, and that was something that attracted you to the position and to the organization. Were there any changes or any effects in terms of the values and the mission of the organization in the change from a community hospital to a tertiary care hospital?

02-00:29:18
Van Renan:
I certainly didn’t see any retreat in the values. If anything, it became kind of that moral compass in your guiding principles. They continued to push and challenge the organization as it completed that decade and into a new millennium. In that hour conversation, the interview with Fred, he also began to kind of lay out that vision, that longer-term vision for Mary Washington Hospital. [30:00] This journey, a very planned journey for Mary Washington Hospital to transition at some point out into the future from a large community hospital to a growing medical center that became an epicenter of care for our region. One of the most rewarding parts of my time with the organization, actually, was in 2013, where we celebrated the twentieth anniversary of the move of Mary Washington Hospital from the Fall Hill campus to its current campus. To be able to talk to community leaders and board members at that time about the thought, vision, and planning that went into the campus. It was very rewarding for me and was part of that attraction to be able to help make that vision come to fruition. I think to a person, if you went back and asked that group, does the Mary Washington of 2013-14 look anything like you would have envisioned back in the early ‘90s? The majority is going to tell you, “No. It actually turned out bigger and grander than we would’ve envisioned.” However, a testament to their leadership was that they set an infrastructure in place that allowed it to grow beyond, maybe, what they might have imagined or even beyond what a stretch goal might have been. They allowed future leaders to put options on the table for them to let future leadership go in new directions. Or if things began to grow faster than they would have ever imagined, it gave you options to be able to do that. It was wonderful for me to get to meet them and to talk to them. You see in their faces how satisfying it is. I wasn’t in the community at the time. You read through some of the old articles and there wasn’t universal agreement in the community about if Mary Washington needed to build a new hospital. How big did it need to be? Or how big should the campus be? It was really a validation of their wisdom and courage at the time, including community leadership. [33:00] Mayor Davies really advocated on behalf of Fredericksburg to say, “We think that move and growth is important to our community and we absolutely believe it needs to be in Fredericksburg.” It was wonderful to have Mayor Davies to be part of that celebration as well.

02-00:33:30
Rigelhaupt:
I would imagine there’s the potential for a change in mission, in the values, or the moral compass, to use a phrase that you just used, when you go through an era of growth like this, and a transition from the community hospital to, really, a kind of regional medical center. I mean, maybe say more about the infrastructure that you described that helped to sustain the moral compass, and the vision, and the mission of the organization?

02-00:34:08
Van Renan:
It goes back to my interview and the conversation with Fred Rankin. Certainly, the clear message that he gave at that time was he was beginning to build a leadership team and an organization of people that shared a common vision, a common commitment to community, and a common commitment to a value system. It was almost like one person, one brick at a time he was transforming the health system. To Fred’s credit, in his time here he’s been at the epicenter of the values. I’ve got people around me that share that same value set and it was hardwired into every conversation that you had, including some of the growth challenges. A risk would be when you are under that kind of intense pressure to try to keep pace with a growing community that you would begin to cut corners, but we had that core group that made sure that was the test. The board of trustees, that was part of their fabric, and they were debating what might be new directions that the organization might be going. It always has brought us back to our mission, vision, and values as an organization. If we go down path A, is it consistent? [36:00] If we go down path B, is it consistent? And this really, I think, served this organization well, and will continue to serve it well, well into the future.

02-00:36:15
Rigelhaupt:
The leadership team that you just described, who else do you remember actively discussing the vision and the path forward?

02-00:36:29
Van Renan:
Certainly Walt Kiwall, who was the chief operating officer for the health system at the time. Nursing leadership with Barbara Kane and with our finance team there’s a cadre. Xavier Richardson from our foundation, who has lived and worked in Fredericksburg his entire life. And if I remember, Xavier was actually born at Mary Washington hospital at the Fall Hill campus. There was this team that Fred began to assemble in his tenure that, again, were folks that embraced that vision. They embraced this core set of values and were really committed and invested in the community. They became that epicenter. They began to recruit new members for their report groups. Walt Kiwall has been a longtime friend and mentor for me and actually gave me my first executive opportunity. I had the pleasure of working with and for Walt for thirteen years as an executive. They were wonderful mentors and they helped reinforce who we are as a health system, where we’re going, the importance of relationships and community, and communication and trust with the medical staff and the associates that we had responsibility for leading. Trust within the community was an important part of the fabric of the organization.

02-00:38:23
Rigelhaupt:
I’m wondering if another way to talk about the fabric, as you describe it, is about a culture of the organization. And I’m curious if you could talk a little bit about how you can recall, in this era of expansion, the second half of the ‘90s, that the culture of the organization lined up with the vision that senior leadership had in the mission of the organization?

02-00:38:52
Van Renan:
There was a rigor to the conversations. It goes back to Fred, back to Walt Kiwall, and other senior executives in the organization during that time. [39:00] There was rigor to their planning and the conversations around what were our needs? Where do we need to go? What are some of the challenges that you would invariably test it back against? Here’s our mission and here’s our vision as an organization. Here is our moral compass and our values. Are we consistent? Is it feeding into who we are as an organization? It really became a natural part of how we conducted business over the time and carried itself to 2000 and beyond.

02-00:39:53
Rigelhaupt:
One of the things that you have already talked about and I would imagine is an important part of sustaining a culture, is communication. And as you’ve described, this is an era of change for the medical staff, that there’s more hospitalists, less physicians rounding in the hospital itself. What were some of the ways that the organization really sought to maintain a culture focused on the mission, focused on the values, when some of the communication channels were changing at the same time as the growth?

02-00:40:31
Van Renan:
You had to look at how the communication that took place. You saw messages from before that time and you would typically have a medical staff business meeting. That was the one place where the entire medical staff would gather together with senior leadership and have those conversations. It became increasingly challenging for the medical staff to be able to attend those. You began to see the need to replicate conversations in smaller environments. Your first choice was always some type of direct conversation, whether it’s in a meeting forum, phone calls, or scheduling personal time. It might be a lunch or might be a breakfast to be able to connect with members of the medical staff, to keep them abreast, and to get their feedback. We put premiums on written communication. What were different venues that you could be able to communicate? As you kind of get into that time, email began to be more and more prevalent and was a new mechanism to be able to communicate. [42:00] But as we grew and the medical staff grew, it was clear that you needed to repeat messages in multiple environments, to make sure that at some point, someone didn’t get missed in the communication challenge, or communication chain. It certainly became increasingly challenging and the communication of today will continue to be that much more challenging. With the advent of, now, smartphones and texting, what are secure networks that you could put into place? That’s a tool and the clinicians and the physicians of today are used to operating with. Being able to push messaging back out and now it’s two-way: you set up the potential for two-way communication to validate that message has been received. The culture in our nation and our world has changed: communication operates in crisp sound bytes. The old medical staff meetings where you might go through two hours of presentations with various overheads, those days are gone. You need to be able to push out small snippets of information in a broad fashion, in multiple environments, and you have got ways to be able to solicit feedback. It takes a little bit longer. It certainly puts some challenges and premium on our marketing communications departments. They’re also now an important part of, what are those important messages that we need to get out? Who are the different constituencies? What are the different ways that we can begin to push messaging out in the organization and to the medical community?

02-00:44:26
Rigelhaupt:
One of the things that you already mentioned, and I was going to ask you directly about your promotion to an executive level position. And I’m wondering if you could talk a little bit about the genesis of your promotion to vice president of clinical operations in 2000.

02-00:44:44
Van Renan:
It has become an interesting personal story. I got my first leadership opportunity back in the ‘80s. [45:00] I saw that I had a knack and interest in leadership. I had come up through the clinical ranks all through my professional career up to that point and I saw the value of being able to not only speak and understand from a clinical perspective, but to be able to marry in the leadership and business parts as well. That would serve future leaders and would certainly make me a little bit more marketable as you got into the future. I set a personal goal for myself, and this was back in 1995, actually. I would do the things, get the right education, and the right experience that would get me an opportunity at some point. I actually set a ten-year goal for myself. Let me back up, it wasn’t in ’95; it would’ve been about 1990. I had set a 10-year goal for myself: I would get those experiences and I would get that education so that within ten years I would be considered a legitimate candidate for a senior level executive position. It really became my stretch goal in those five years from ’95 when I joined Mary Washington Hospital. At the end of the day, it’s about the quality of your work and the results that you produce that allowed me to be a candidate and to be considered when an executive position opened up in May of 2000. I certainly was very blessed and honored for that opportunity, to kind of get that first executive role. I remember sitting down in Walt Kiwall’s office, and Walt was the administrator and chief operating officer for Mary Washington Hospital at the time. He offered me the position. I learned a great deal from Walt over the years. He is a wonderful human being and leader. Walt gave me some words of wisdom and said, “One of the things you’re going to have to learn, or have to experience, is that up until now in your career in leadership, you have been the content expert in everything that you’ve had responsibility for. At the executive level, you are going to stop being the content expert on everything. You’re going to need to be able to develop yourself as a better and better general manager who has the ability to have the right conversations, to be able to find your content experts, get the right counsel, and collectively be able to make decisions.” [48:00] Walt was right, absolutely in spades. There were some difficult times when you tried to just study—you run out of time because it wasn’t just the cardiac program that was part of our group. I had about half the clinical programs in the hospital at the time. You just run out of time to be able to try to study and know everything about everything. There were some difficult lessons along the way. I’ve taken what I learned and as I’ve mentored new leaders and made presentations, one of those cautions and pearls of wisdom that I give them is that if your professional goal is to rise up through the senior executive ranks and beyond that you are going to need to develop that ability to be a very good general manager. It’s about relationships at that point and really making connections to your content experts, pulling in wise counsel, and collectively making decisions. It’s the success of those teams that ultimately is your reward. That’s how the success measures. It’s not that I needed to know everything and make all of the decisions myself. It really became about teams and the teams I had responsibility for, for them to be successful, and to feel very satisfied with the quality of work and care that they were providing.

02-00:50:07
Rigelhaupt:
So, you said you were supervising about half of the clinical lines? What were some of the programs and lines that you were supervising?

02-00:50:14
Van Renan:
It would change over time as new leaders would come and go within the organization. But initially, I still kept responsibility for all of the cardiac programs, including my first opportunity to have, actually, nursing units to be part of that compliment—the critical care units. I had the challenge, at that time, to begin to identify and mentor someone in the organization to begin to kind of take over the day-to-day operations of the cardiovascular program. I had a lovely nurse that had worked for me and was part of our telemetry group at the time. [51:00] Really, I could see she had real talent, Lisa Lucas. I began to mentor Lisa to be able to take over the reigns of the cardiovascular program. Also, I had a respiratory therapy and pulmonary services program and I began to pick up aspects of our medicine inpatient units, including those critical care environments. And at different times, pharmacy may have been part of the product group for some period of time. Or I think in and around that time, I had my first opportunity to get connected to our pathology service. So I’ve had a connection to the pathology department and its growth since 2000. I am very, very proud of the accomplishments and growth of that group. It was later in my tenure that I picked up responsibility for our home health and hospice programs and our cancer programs, including our radiation therapy program. It was new opportunities to be involved with patient care groups that weren’t part of my original clinical training, which I think, I maybe had mentioned at our first meeting, I really grew up in the cardiovascular pulmonary medicine and critical care side of health care. To be involved in cancer care and some other aspects was really interesting and challenging. I got to know new people and new patient groups. I was wise enough to know I would never become the content expert, but you had to take a step back to do reading, attend conferences, and be able to get a foundation in place that allowed you to be a good senior leader and represent these caregivers, medical professionals, and patients.

02-00:53:26
Rigelhaupt:
It sounds as though it was not consistent, that the position as vice president of clinical operations had these lines; that it changed, some of the departments that you were supervising. And maybe, if you could talk in general terms, because it sounds like there was a number of changes over you’re your time in the position. What were those conversations like? How and why did the organization change what you were supervising, or someone else was supervising? You know, how did those decisions get made?

02-00:54:00
Van Renan:
It typically was either a couple of different major kinds of impetus for reshuffling. If there was a new service that might be brought in that required an executive to be able to devote more of their time and say, “Okay. Looking at their portfolio, are there some things that we can redistribute?” More times than not, people join or leave the organization. When those kinds of leadership changes take place, it’s an opportunity to kind of take a step back to say, “Is there a better way to connect leadership responsibilities?” Part of Walt’s commitment to me and to the other executives was he would look for new learning opportunities. Sometimes it would be here. Walt would make a decision and say, “I’m going to make a change because I see this as a learning opportunity for you, to get you experience in something that you’re not used to having responsibility for.” There were points where you began to have responsibility outside of a clinical environment: the food service department, housekeeping, engineering, and other groups were part of your report group. You began to learn in a prescriptive fashion. Walt did a wonderful job, as he would sit down with you each year at performance appraisal time. Not only is it a reflection of, “Hey, how did last year go?” But he wanted to have that conversation with you. That was part of the fabric of the organization to say, “Where would you like to be at some point? What are the things that were missing in your portfolio that we need to look for as learning opportunities?” It was intended to be able to kind of go in and put it into place. Certainly, there were some challenges along the way and Walt and I will still joke about it, probably, until today. If Walt began the conversation with, “Hey, do I have an opportunity for you.” Sometimes, you had to say, “Okay. Let’s talk a little bit more, Walt, about this opportunity.” [57:00] But you saw he had a confidence in you sometimes as a challenging situation might pop up. You had earned his confidence and trust for him to say, “Okay. I’ve helped mentor this guy and he’s at a place where I’ve got a confidence that he’s going to be able to kind of get in, understand a situation, and give good counsel back to me, to Fred, to senior leadership about here’s what’s going on. Here are my recommendations about what needs to take place.” As I said, he was a wonderful mentor and friend and I learned a great deal from Walt.

02-00:57:35
Rigelhaupt:
What are some of those opportunities that he presented that stand out to you as memorable, or that you feel like you made a contribution? If you could talk generally about those opportunities.

02-00:57:47
Van Renan:
I forget the exact time frame—this would’ve been some place between 2000 and, say, 2004. At that time, we actually had two home health services and a hospice service, all of them independent of each other. Sometimes, actually, in competition with each other, and certainly, there were times where all three of them may have showed up on a block and people were getting out of their cars, sometimes, seeing the same patient, sometimes seeing different patients in a geographic area. You could see at that time, there was probably a better way to do that and to do a better job of coordinating this service. One of the things that Walt asked me to do was to go and to take an in-depth analysis of the two home health agencies, one of which was a joint venture with other providers in the region, and our hospice group. At the end, it was really clear to me that we needed to, actually, close one of the businesses. That was one of the more difficult things I’ve had to do in my professional career: to sit across from a group of associates and let them know that we were closing the business that they worked in. However, also in that, we saw an opportunity to be able to kind of bring together—they all had a common infrastructure and leadership and there were ways to bring that together under a centralized leadership in a centralized location. [01:00:00] That allowed us to not replicate inefficiently the infrastructure, but also to do a better job of coordinating our resources so that when we were seeing a patient, it was one caregiver that was showing up in that location and not three different groups. It’s one of the things, you know, as I look back at my nineteen years with the organization that I was really proud of. In and around that time, after we had began to coalesce those businesses into a single business, a coordinated business, that offered both home health and hospice services at a single location, we were in the need of finding someone to direct this new business. Through a professional contact, I was given a name, Eileen Dohmann, who was a very experienced home health and hospice leader in Northern Virginia. We joke about it today, but my first day, my first opportunity to meet with Eileen I took her to one of the downtown restaurants where one of their specialty fares was a buffalo burger. And so on our first date, I bought Eileen her first buffalo burger. There was immediate connection with Eileen. I could see that she had the same kind of fabric—back to Fred—and what was he looking for in leadership. She came with that same kind of mindset and abilities. I was able to convince her to join the organization and to lead. I made a prediction to Eileen literally after that first conversation. I said, “You know, I think you would be a wonderful addition to this organization. My prediction is that at some point in the not too distant future you’re going to be an executive in this company.” When I got promoted to senior vice president and administrator at Mary Washington Hospital and Walt gave me the opportunity to pick my leadership team, Eileen was one of those initial individuals that I asked to be part of my senior leadership group. I gave her her first opportunity to be an executive in this company. We have remained fast friends over those years. But, you know, kind of back to your original question: it was a challenge and you had to have some difficult conversations. [01:03:00] We had to make some difficult decisions as an organization to close a business and you don’t do that lightly. However, in doing that, you have to make sure that those individuals, those associates, had an opportunity to connect some place in the new home health and hospice agency or to help them find new connections in your organization. Still, today, I’ll bump into associates that were in that room when I gave them the tough message, “We’re closing this business.” I still see in the hallway. We still stay connected. Many of them are working here—it might be in our information services division or other parts of the company—and we remember those times. They felt a level of trust and confidence in the organization’s senior leadership, that we were making the right decision, and they, as an associate, were really important to us as an organization. We were going out of our way to do everything that we could to make sure that they had a way to provide for their family.

02-01:04:23
Rigelhaupt:
I imagine that there were things you learned when you got your new position as vice president that you might not have known until you were in the position. You know, not like a curtain went up, but you just see things differently. You have access to different information, you’re making different types of decisions. What were some of the things that you remember learning about the organization or seeing differently as you began working as a vice president in 2000?

02-01:04:56
Van Renan:
I mean certainly, the number of opinions and viewpoints that you had now funneling to you through all of the various programs that you had responsibility for became pretty daunting at times. To be able to kind of sift through different viewpoints of the beach ball and different sets of needs. Really, it was your responsibility. When I started, I just had responsibility for the cardiovascular program. I needed to really make sure that I was thinking, first and foremost, what was in the best interest of the community, the patient, health system, and then specific programs or individuals? They got farther and farther away. [01:06:00] You had to make broader decisions and to make sure, over some reasonable period of time, everyone had an opportunity to get additional capital that they might have needed, or programmatic health, or special resources—at the end of the day they felt that they were being heard and they were an important part of what we provided to the community. Also, to pull them into the conversations to say, “Hey, if we only have X dollars, what’s the best way for us to spend that?” It might not have been their program, but at least they had an opportunity to be part of that conversation and know that, okay, my time might be coming up in the future at some point. That was an important part of learning, as you had broader and broader responsibilities in the health system.

02-01:07:10
Rigelhaupt:
Did you gain a different understanding of the business model and business models in health care when you entered this position?

02-01:07:22
Van Renan:
I don’t know if it was new learning. I think it was a reinforcement of learning that you’d had before, and certainly part of your education. Being a not-for-profit sole community provider at the time, not everything is going to make money. However, it is a critical service that you need to be able to provide to the community, in a way that allows it to do a wonderful job, and to continue into the future. It does put a little more pressure on other aspects of the business to be able to help support the infrastructure. It was being able to kind of look at the economics of care and then just all of the various interrelationships of care. Your critical care team had all kinds of different patient populations that they have responsibility for. Being able to make sure that you had all of the right technical abilities, training, and equipment for them to move across a continuum of patients was a challenge. [01:09:00] You had to be able to keep taking more and more of a macro view of the organization, what was going on, and how patients flowed from A to Z in the health system. Within Mary Washington in particular, knowing that if there were points where that flow began to slow down or stop, what is the impact of patients and caregivers that were either downstream or upstream from that point? Part of that kind of learning and early work was just trying to get that understanding and beginning to create new efficiencies in just how patient care was taking place and the flow within the organization. We were pushing towards where even after that tower expansion, it didn’t take very long for those new 100 beds to fill up. There were days where you had more patients here than we had physical beds. You were providing care in different points of the organization that are typically not set up to do day-to-day patient care. We were growing so rapidly. Now starts the conversations about do we need to expand again? If we need to expand again, where is that? Is it another tower at Mary Washington Hospital? In the original plans—back to the wisdom of the board of trustees and leadership back when we were planning the campus move and the new hospital as they moved from Fall Hill—the fifth floor and the core of that original construction actually allowed you to put two more floors above that. However, that’s very expensive to do and it’s very disruptive to care. We talked about, if we were expanding should we build another tower out front? Or is there some part of the campus, including should we build some type of inpatient care structure on the campus? It might not be physically attached to Mary Washington Hospital. [01:12:00] In that time there were conversations about should we look into the counties, Spotsylvania or Stafford? There were a lot of conversations around just the challenge of anyone living north of the Rappahannock River and the challenge for them on many days, to get across the river, whether it’s the Falmouth Bridge or I-95. Ultimately, out of those conversations was, “Yeah, we’re going to need to grow again. We’ve outpaced even the now 427 beds that Mary Washington Hospital has in the bed compliment.” But that next growth iteration—the only way to meet the needs of Stafford County and to be able to address those patients getting here was to look at building a hospital up in Stafford County. That were those conversations and the thought process that culminated in the building of the Stafford Hospital.

02-01:13:29
Rigelhaupt:
One of the things that you said early on in this response that you just gave was that not everything in the hospital makes money, and that’s part of being a sole community provider. Not every program is going to make money. And this question is really about, you know, the importance of revenue, and the business of health care, and Mary Washington Healthcare. Also in the context of in an interview, a board member said to me very succinctly, “If there is no margin, there is no mission.” That the organization may be mission-driven, but if there is no margin, there can’t be a mission. And I’m wondering, you know, if you could think back, perhaps, early in your position as vice president, what do you remember about some of the conversation about that balance between mission, and margin, and revenue, and how those decisions were made?

02-01:14:38
Van Renan:
That was also part of this: incredible growth that we were seeing in the region. We were investing a great deal and I think it is a testament to the board of trustees and their commitment to this community. You take it back to the beautiful campus and buying ninety-three acres. No one thought you would ever need a ninety-three acre campus. [01:15:00] The beautiful facility and setting it up such that it allowed for future growth. You spent some extra money at that time just to make sure you had options available. As Mary Washington’s role in the region began to change, changing from this large community hospital to a more tertiary level referral center, it was about what were the new clinical needs? What was our community like? What was this place and that you continued to allow Mary Washington Hospital to evolve into this regional referral center? What were those new elements that you needed to add? You needed to manage operations well enough that you not only paid the bills because you had salaries to pay. Mary Washington Hospital, today, every two weeks, our payroll is about $5 million. I never would have thought in my wildest imagination that I’d have that kind of a checkbook to have responsibility for. You need to manage your operations such that it allowed you to attract and retain the best and brightest, you had the right supplies, and gave you enough money for the right technologies. Those technologies, they began to age—there’s a planned replacement so it’s not a one-time cost. You have got to have something leftover that you can put into your savings account because there will be that time that comes up that says, “I need to build a 100-bed tower. I need to build a new hospital up in Stafford County.” There will be a place in the future where someone that is sitting in my seat will be planning the replacement of this hospital. You have got to have saved some money. I tell associates that managing the economics and the finances of a big complex health system and a complex business like Mary Washington Hospital, actually, is a lot like the things that they do in their personal life. They’re managing a checkbook. They know there is money coming in and money going out and they’re saving for future needs. [01:18:00] The only thing that changes is the number of zeroes on the end of that responsibility. These are things that each of us have some level of understanding and experience in. It also takes some kind of forethought. You’re looking out ahead and making sure you’re doing things wisely that sets the table, or puts you in a position for the place you want it to be, including being able to save. Just like at home—so, in our personal life, it’s our credit score. In the health system business, it’s your bond ratings. That really becomes your kind of credit score, your credit worthiness. The better that score is, you’re able to borrow money at a lower interest rate. That also puts a premium on making sure that you do a good job. The health system is not paying stockholders. It’s not like we have $1 billion in the bank just sitting there gaining interest. I think during my time, if you look through just about everything that we had saved and you were able to kind of mark that dollar, it didn’t take very long before it got reinvested again. It’s this constant kind of re-nourishing and regeneration of the health system. Economics are a part of it. So sometimes people say, “Well, you’re a not-for-profit organization.” Being not-for-profit means we’re not distributing the profits at the end of the year. That money is retained and is reinvested. Every penny of it goes back into this organization and this community. If we would ever go out of business, actually, after all of the creditors are paid, I believe, the money actually goes back to the city of Fredericksburg which kind of helped get us started back in 1899.

02-01:20:36
Rigelhaupt:
In these conversations, the organization is making difficult decisions about where to invest, about where to have to close things. [01:21:00] Do you recall that you brought perspective with your background on the clinical side, having been a nurse, and been in respiratory therapy, and really having worked on the front lines of direct patient care, that you brought a perspective that other senior executives might not have experienced.

02-01:21:09
Van Renan:
I think it was an important role that I played being part of, now, the senior leadership team. Often times they would look to my end of the table for some thoughts and perspectives from a clinical standpoint. In that period of growth, you had our first chief medical officer and you had an executive vice president who was a physician. You had other clinical representation, including medical staff, being part of those conversations. I think one of the blessings for me in this long path to go from the bedside clinician to actually starting as a nursing assistant—there might have been a shorter route to take. But looking back over my experiences, in hindsight, I wouldn’t have traded or short-circuited any of those because they were valuable lessons and perspectives. I brought it to the table. I brought what it was like to be a nursing assistant working nights turning orthopedic patients, back in 1976—that was helpful. You know, I felt the conversations. You were able to get a kind of balanced view of the landscape and I think we made good decisions along that time.

02-01:22:49
Rigelhaupt:
Could you talk about your promotion to senior vice president, and Mary Washington Hospital administrator in 2006?

02-01:22:56
Van Renan:
Candidly, that was a complete surprise to me. Now at 2006, we made the decision and received a Certificate of Public Need and the “Okay” to begin to plan and begin to build Stafford Hospital. I really thought that maybe the next learning opportunity for Walt, they could provide me, would be that I would ultimately go to Stafford Hospital, which was a little bit smaller of a hospital to kind of get that learning. It wouldn’t be until my sixties, actually, that I might get the opportunity at some point to lead Mary Washington. [01:24:00] Walt brought me into his office and I remember very vividly the conversation. Walt has got a wonderful sense of humor. He jokingly started the conversation with, “Have I got an opportunity for you.” But, you know, what he said was, “Here, I want you to take over the day-to-day running of Mary Washington Hospital. That would allow me to devote all of my time to the planning, organization, and construction of Stafford Hospital.” I was absolutely floored and certainly blessed for that kind of opportunity. I would have never imagined having the responsibilities that I have today. That was never really on my radar screen, as a nursing assistant in ’76, turning orthopedic patients in the middle of the night, and then being the executive over a 437-bed tertiary level medical center. That was never on my radar screen or part of my career planning. The other blessing or opportunity in that time was the opportunity to hand pick my executive team. I was able to go back out and pick people that I had great confidence in and great trust in not only their leadership abilities, but their technical abilities. To be able to go and give those individuals that first opportunity for them to be executives was priceless. They will forever be friends, professional friends. It’s almost like being classmates. I could see us as our times invariably wrap up in the health system having kind of an alumni day where our graduating class, this group of executives, reconnects in our lives. You’re able to help mentor them along their leadership journey, to pass along the things that I was blessed to learn from Fred, from all others along my experiences, and to help prepare them for new opportunities. [01:27:00] It was just an incredible day for me to get that opportunity.

02-01:27:11
Rigelhaupt:
What were some of the things that you learned about the organization, as you began this new position?

02-01:27:16
Van Renan:
Often times when I’m giving a community talk and often I feel like I’m the mayor of Mary Washington Hospital. It’s like a small city and a city that never sleeps. I grew up in Nebraska and there are a lot of towns and communities in Nebraska that do not have as many people as Mary Washington Hospital has working for them. Probably at our peak, we had 2,500 associates that were Mary Washington Hospital employees. In that, you had volunteers and you had medical staff. You had responsibility for not only providing care to the community, but you had to worry about and you had to feed them. You had food service, cleaning needs, power, water, heating, and so you had things that a mayor sometimes has to deal with in their day-to-day responsibilities of running a city. It was taking time to really learn other aspects of the organization that had never been part of my report group. To be able see what were all of the connections that needed to take place and to try to look at things from a patient and visitor perspective. It was, as I said, I mean, just an incredible blessing to have that kind of responsibility and professional challenge in your life. I just would’ve never ever imagined—you know at one point, I think my operating budget at Mary Washington was about $500 million. Never thought I’d have a checkbook with $500 million of responsibility to it. [laughter] Starting at the clinical level, as a nursing assistant, and getting progressive responsibilities, and setting an infrastructure, an experience base, prepared you for this challenge. [01:30:00] Being able to kind of pick teammates that you had an incredible trust in the communication and the link to, just made the journey that much easier. For me, I was very blessed to have an incredible leadership team around.

02-01:30:22
Rigelhaupt:
You mentioned Eileen Dohmann earlier. Who else did you pick to work with as part of your team?

02-01:30:30
Van Renan:
It was Eileen Dohmann, Marianna Bedway, who is, today, the chief nurse executive at Mary Washington Hospital. Marianna and I actually started working together within the first few months of me joining the health system. We stayed friends and stayed kind of connected in the organization over that time. She had responsibility prior to that for our emergency services department. She was really an important leader in that transformation of emergency services. At its peak, we were seeing about 106,000 patient visits in our ER at Mary Washington alone. She is an incredibly intelligent, wonderful, lovely individual, and a great, great leader. Marie Frederick, who is an executive in the company has our properties and outpatient division. And then James Swisher. Those were the four individuals that were part of my direct report group, and this little, kind of, graduating class.

02-01:32:14
Rigelhaupt:
There are also challenges that the organization has faced since 2006 and that you confronted as the administrator and senior vice president. What were some of the challenges that were most difficult for you to confront?

02-01:32:36
Van Renan:
I think if you would ask this same question to the group of executives, our greatest challenge in that time frame, from 2006 to 2009—February of 2009 was the opening of Stafford Hospital—was we were the sole community provider. [01:33:00] Great portions of the year, and certainly during the wintertime, we did nothing else in our day other than trying to provide patient care in environments that were not set up to provide patient care. Times where you would think we’re at gridlock and we were going to have to try to transfer patients to some other community for care. We had to find a new creative solution that allowed us to kind of bring that patient in. Those were very challenging times for us and really tested, I think, the mettle of the leadership team. You knew help was coming, but a new hospital and a new medical staff doesn’t show up overnight. This was 2008. If we have 437 licensed beds at Mary Washington Hospital, over forty of them are actually over at Snowden at Fredericksburg and they’re dedicated to behavioral health. You’ve got another fifty-plus that are OB/GYN beds. I can’t send pneumonia patients. 437 licensed beds and I remember times where we had upwards of 450 patients some place in the hospital that we were trying to provide care to. I was hoping that I could get the right bed in some reasonable period of time. 2008 was also the year that you had 106,000 patient visits in our ER. Walt and the team that was, you know, devoted to Stafford. They were able to get that project design built ahead of time. What was driving them was they knew what we were trying to do and what we were dealing with every day in 2008. They knew we needed to get some help to the clinical teams to be able to provide a place for rest and care for our community. That was much of what we were all about in that 2006-2009 time frame.

02-01:35:46
Rigelhaupt:
And at the same time, in year that you just mentioned, 2009, Mary Washington Hospital achieves an important milestone, the nursing programs achieves Magnet status. [01:36:00] So, even the hardships of the day-to-day of where do we put people, there’s growth. What did Magnet, achieving the Magnet status mean to you?

02-01:36:14
Van Renan:
What are those highlights of your personal career? I’ve got a list of five that say here are the ones that really stand out in my mind. One of those is achieving that status because that is literally the highest bar from a nursing patient care perspective that you can attain. It was one of those programs. It will kind of take us all the way back to that cardiac surgery. What did cardiac surgery do? It put a new bar out there for the organization to say, hey, with the right resources, and attention, and leadership, and commitment, we can attain some pretty incredible things. You saw new things come up over that time frame. One of those was nursing care. As you pointed out, even during a very, very challenging clinical care time in our organizational history it demonstrated the quality of nursing care, nursing practice, that we had put together in this organization over those years. At the inception of the cardiac surgery program, neurosurgery, trauma, as you continue to delve out, that brought new training and experience to the organization. I think it was a real testament to nursing and leadership at that time: Barbara Kane, who was our chief nurse executive for the health system during that time frame and Marianna Bedway and Eileen Dohmann, both of whom are nurses, and were nurse executives at Mary Washington Hospital. It’s a testament to that group’s work and vision that they were able to put together in a validation of the great work and potential that was out there within the nursing ranks.

02-01:38:38
Rigelhaupt:
You said there were five milestones. One of them was Magnet status?

02-01:38:44
Van Renan:
Yes.

02-01:38:45
Rigelhaupt:
What are the other four?

02-01:38:47
Van Renan:
The other four, and not in a particular order, with the exception of the last one, and I’ll tell you the one I’m the proudest of when it gets to the end. [01:39:00] Our trauma program—I’m very, very proud of because it took a tremendous amount of planning and commitment on behalf of the board of trustees and senior leadership in the organization to put this infrastructure in place. You had to go back to say, here, we needed 100 more beds, we needed to upgrade our ORs and our ICUs, and all of this technical and facility infrastructure. And then on top of that, to attract and retain the best and brightest from a trauma surgeon, critical care, EMS perspective, and then the other medial subspecialties. To be able to attain that and then within a year after getting that Level II trauma designation by the state attaining American College of Surgeon accreditation. It was unheard of, you know, in the state. I am very, very proud of that service and the growth and commitment of the team. I’m very proud of being a part of that twenty-year journey that we describe with the move from Fall Hill to this campus, the conversation with Fred, and the transformation of Mary Washington Hospital from being a large community hospital into a medical center. This year, we received notice from US News & World Report that Mary Washington Hospital—and they publish a national rating each year—Mary Washington Hospital ranked number six out of, I think, 128 hospitals that they studied and rated in Virginia. That meant a lot to be number six out of 128. That’s a top five percent performance. I am very proud of that accomplishment. The penultimate one and when my time with the health system wraps up—my name’s not going to be on a building some place or a program. But my legacy and the thing I’m proudest of are the leaders that I’ve had an opportunity to mentor and grow. One of the things that I bring and I value and I brought to the organization over my time, has been an eye for talent and to be able to kind of see people with an ability and get them in the right opportunity to help grow and nurture that. [01:42:00] Those folks, they become your legacy. They take things and learning from my leadership DNA and make it part of their leadership DNA. They, in turn, are passing it on to somebody else. And so, generations from now, if there was such a way to say isolate leadership DNA, I might show up at some point centuries from now. Really, that’s what I’m proudest of the most. To look across the organization and people that I’ve had an opportunity to be in a relationship with, and grow, and mentor, and to see them rise to new levels of responsibility. That means a lot to me. It’s one of the many things that I really enjoy and it’s an important part of my job as an executive. It is something that I learned from Fred and I learned from Walt. We’re all teachers and an important part of our leadership responsibility is teaching and mentoring. I really, really enjoy that part of my work.

02-01:43:25
Rigelhaupt:
How would you talk about and describe Mary Washington Hospital, MediCorp, and now Mary Washington Healthcare, the community benefit practices?

01:43:36
Van Renan:
We offer a lot to the community in these increasingly challenging economic times. More and more people don’t have insurance. They don’t have access to any kind of insurance. Or at the very least, they don’t have the resources to be able to pay whether it’s co-pays now or we went from deductibles to super deductibles, and that’s continuing to grow. We still provide the same level of care to everybody that shows up of our door, independent of their ability to pay, or whether they’re insured or not. We offer services and things that, at the end of the day, don’t have a positive bottom line, but they’re critical to what our community needs. It’s part of that fabric. It’s part of this now 115-year history, this very profound, deep, rich connection, and responsibility, starting with Mary Washington Hospital becoming Mary Washington Healthcare, a health system. [01:45:00] This connection to the community, this deep responsibility that we have, and blessing that we have to care for Fredericksburg and the surrounding counties. We don’t take it lightly. And back to Fred and back to ’95 and sitting in his office: you could tell that was part of who he was and part of what he was looking for in people that he was bringing in to his leadership team. It was one brick at a time where people shared that same kind of passion and commitment to community.

02-01:45:46
Rigelhaupt:
Thinking about your role as the administrator of Mary Washington Hospital, what do you see as some of the benefits to health care in the community through the grants given through the Community Benefit model?

01:46:03
Van Renan:
There are certainly lots of services and organizations out in the community that are absolutely necessary to different subsets of the community. Those organizations could not exist without our donations. One of the things, I think it goes back to Fred again and his legacy. And it was Joe Wilson who was, I believe, the chairman of the board of trustees at the time. They said, “Hey, we’ve had a good year.” I forget where in the history, but they set aside some seed money that they began to try to invest and grow. Then you take the earnings off of that and keep reinvesting. It began to perpetuate itself, this Community Services Fund. We’re going to look back decades from now to say that was one of those really important milestones and commitments on behalf of the board of trustees and leadership. The Moss Free Clinic that is here on our campus and Mary Washington Healthcare and I helped build. If you’ve ever been in there, and if you had an opportunity to go to any other kind of free clinics around the state, or whether it’s across the country, it is a beautiful facility. It’s a modern, beautiful facility. It absolutely is a testament, again, to the board of trustees, to leadership, to community leaders, and community members who generously gave out of their personal bank accounts to help fund that. To find that resource, I think, speaks volumes to the community. [01:48:00] There will be more challenges like that as health care becomes more expensive and as the economics of our country becomes more challenging. We go through these ebbs and flows of the economic cycle, and it puts some strains on systems. For 115 years we have remained committed to the community and to make that level of sacrifice.

02-01:48:40
Rigelhaupt:
So, hospitals have a long history of community benefit through charity care. And as you described, anyone who comes into the emergency department is going to be treated regardless of their ability to pay. And there’s a lot of uncompensated care in this hospital and hospitals throughout the United States. And even through Medicare and Medicaid in particular, that the reimbursement rates don’t cover the cost of care. And yet, as you described, through the Community Benefit Fund, grants that you’re giving out, this is something different. And when, in fact, there are tens of millions of dollars of uncompensated care. One might say, “Isn’t it perfectly reasonable that the foundation reinvest that money in the hospital, and in the health system?” And yet, the organization has committed to giving out these grants to support the health in the community and support other organizations. Why do you think it has chosen to sustain that level of commitment outside of the organization’s walls?

02-01:49:55
Van Renan:
The foundation does invest back into the hospitals and health systems as well. Over time, there will be special projects or fundraising efforts. Our regional cancer center is a good example: you had a very focused campaign to be able to help fund, or at least offset some of the infrastructure to put that resource together. It’s part of the organizational philosophy and part of the Community Service Fund that their investments are outside the walls. The typical health care that can help prevent patients being admitted to the hospital. That it can be as simple as, you know, the basics. [01:51:00] It’s food, it’s shelter, and it’s clothing, or special support systems for unique aspects of the community that don’t have the resources. It’s a place to connect and have people to tap in. You know, invariably, if you ignored all of that, at some point, they’re going to be at your emergency room door. That’s probably not the thing that you want to happen. There are ways to invest, to help, at the very least, postpone that, if not prevent it. That is part of the foundation. That philosophy and conversation with the foundation board to say what are the right investments that we need to make and have the definition of health care become broader and broader. They are necessary investments for prevention. There is a cost savings opportunity. I’ve prevented a more costly resource-consuming care situation by making an investment some place out in the community.

02-01:52:25
Rigelhaupt:
But also, what you are talking about is preventative care and primary care, which in the history of hospitals in the United States, even not-for-profit hospitals and acute care medical centers have not necessarily been the focus. It has been acute care, and it has been things like the cardiac programs, and you know, higher tech medicine. And it sounds like there has been a continual emphasis on preventative care and primary medicine in the organization. Where did that come from and how has it been sustained?

02-01:53:00
Van Renan:
It goes back to our mission: it’s improving the health status of the communities that we serve. That definition, in all my time with the health system, has still been very broad. It’s not hospital-focused. That mission has still resonated in my nineteen years. You had conversation opportunities to make sure that you were putting community infrastructure in place that also addressed outpatient prevention strategies on behalf of the community because that is part of improving your health status. As health care resources get even more stringent and less as we move into the future, it’s going to require prevention. [01:54:00] At its core though, each of us as citizens, have to be willing to adopt a change, a personal change in our life. And so, if I’m a smoker, I’ve got to be willing to do the things that help me stop smoking. It is sensible exercise and a sensible diet. Things that we have known for decades, and we as a society have been slow to, or resistant to embrace, that are ultimately going to have to grow as well. The penalty that each of us pays in our copays and deductibles for not adopting some of those changes in our lives gets to be larger. Eventually, you reach a point and it gets your attention. It won’t prevent everything, but we can, as individuals, improve our own health status, the health status of our family, and at the very least postpone times that we might need more complex care. Care will move farther and farther out of the hospitals and into more community-based environments in trying to prevent patients from coming to the hospital. What could happen is, at some point, actual inpatient acute care bed need is much smaller than it is today. We’re not to that day yet. People have been predicting we’re going to be at that day for decades. Back to the late-1980s and early-1990s, when they were talking about do we need to build a new Mary Washington Hospital, there was a pervasive believe that hospital beds were going away. We are here twenty years later, and there are still a lot of patients coming to our door that absolutely need the care that we provide.

02-01:56:39
Rigelhaupt:
So, this is a long question, and I think we’re coming close to time, but I want to hear your thoughts on this. One of the things that I’ve heard in these interviews is that Mary Washington Healthcare is community centered. The mission of improving health status of the community is really core to how decisions are made. [01:57:00] And yet, it’s also evident, you know, that since the 1970s, and increasingly so since the 1990s, Mary Washington Healthcare and hospitals in general, interact with really powerful external forces, from questions of finance, to bond markets, the center for Medicare and Medicaid Services, and how they reimburse and change their reimbursement rates. Insurance companies and other third-party payers, the need for technology, and it’s not low-cost technology by any stretch of the imagination. There are market forces, and increasingly, competition with a competing hospital just five miles from here. How, with all of those external forces, does the organization maintain its focus on the community?

02-01:57:55
Van Renan:
I would so offer, it’s back to this commitment of mission, vision, and values. That’s the moral compass. It’s the epicenter of who we are as an organization. It is today—and I’ll predict going into the future—it is still so passionately embraced by the board of trustees, senior leadership, associates, and that is what drives it. Is our job radically different and more complex over our collective tenures? Absolutely. Back in the late-1970s and 1980s, I never would have imagined what care, and hospital care, and the challenges of today would look like. We might not be able to imagine it, even going back, say, ten years. I’ll take it back to Fred again and I’ll give Fred credit. He understood that to help navigate the turbulent waters were going to be going into the future required leadership. Back to Fred, he is going and finding one person at a time to say, “Hey, this is somebody that I think can help this health system in this community.” I’m not sure what’s coming out here on the horizon. We might have a pretty good guess in the next three to five years, but beyond that, it might be challenging. At the end of the day, he went out and found the right leaders to help navigate where we’ve gone as an organization. To have that opportunity and to be part of Fred’s leadership team, I will be forever grateful to him for that opportunity and for his friendship and mentorship over that time. [02:00:00] A lot of who I am as a leader, I give credit to Fred and then to Walt. Both have, really, invested a lot of time in me as an individual to kind of help shape me. There will be a time, we’ll fast-forward twenty years from now and somebody—we’re doing kind of a forty-year retrospective. Whoever is sitting in this chair at that time, they’ll look back at this time and say, “Remember the good ol’ days back in 2014?” Maybe that’s the one constant? I just passed my thirty-eighth anniversary in hospital-based health care. Part of that constant was there is constant change and evolution that takes place. I was really blessed to be part of organizations that invested a lot in getting the right leadership, had the right board of trustee commitment, and were passionate about our communities. That allowed you through conversation, hard work, and thought, to keep pace with whatever changes re coming down the pike.

02-02:01:23
Rigelhaupt:
I think we’re at time, and the way I like to try and end is to ask two questions. One, is there anything that I should’ve asked that I didn’t, and two, is there anything you would like to add?

02-02:01:40
Van Renan:
The interview was very well done and researched. I think you’ve asked all of the right questions. Are there some things that I would like to add? I mean, nothing that really comes to mind. I was excited to be a part of this and to know your legacy has been recorded and available twenty years from now. Or maybe one of my grandkids might be doing some research and pulls up a picture of their grandfather in 2014 talking about this journey. I just appreciate being part of this really important twenty-year span in the health system and in the 115-year history, of Mary Washington Hospital. I have a confidence in the team that I’ve assembled. When my time comes to an end they are going to continue that same commitment that I’ve had and that I learned from the Freds and the Walts along my journey.

02-02:02:46
Rigelhaupt:
I think that’s a nice place to stop.

02-02:02:48
Van Renan:
Thank you!

02-02:02:49
Rigelhaupt:
Thank you!

02-02:02:50
Van Renan:
You bet!
[End of Interview]

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