Walter Kiwall

Walter Kiwall started at Mary Washington Hospital in 1991. Prior to joining Mary Washington Hospital, he had worked as an administrator at Washington Hospital in Pennsylvania. He began as a leader in the human resources department. He was promoted to Vice President of Human Relations first on an interim basis, but the position soon became permanent. He was promoted to Executive Vice President and Chief Operating Officer (COO) for Mary Washington Healthcare and President of Stafford Hospital. Kiwall was instrumental in the planning, construction, and opening of Stafford Hospital. As COO he had executive responsibility for the operations, business development, and system development of the health system. He has undergraduate degrees from Pennsylvania State University and the California University of Pennsylvania in engineering and business. He received an MBA from the Joseph M. Katz Graduate School of Business at the University of Pittsburgh. He retired from Mary Washington Healthcare in 2013.

Walter Kiwall was interviewed by Jess Rigelhaupt on October 14, 2013, and November 1, 2013.

In addition to the transcript below, a full transcript of this interview is available as a PDF file in the University of Mary Washington’s Digital Archive.

Discursive Table of Contents

Interview 1 – October 14, 2013
00:00-15:00
Introduction—First day of work—Orientation—Strengths of Hospital—Administration—Core values—Community—Duties—Management—Challenges—Growth—Population Growth—Sub-specialists—New hospital—Nursing

15:00-30:00
Military nurses—Physicians—Administration—MediCorp—Fred Rankin—Hospital size—New hospital—Population growth—Risk—Business—Ancillary facilities—Primary care physicians

30:00-45:00
Primary care physicians—MediCorp—Private practice—Tension between hospitals and physicians—Growth and development—Resources—Investment—Challenges—Changes in health care—Construction

45:00-01:00:00
Construction—Challenges in new facility—Navigating new facility—New hospital—Growth—Emergency department—Trauma program

01:00:00-01:15:00
Trauma program—Recruiting—Opening new facility—Primary care—Hospitalists—Physician offices on campus—Planning campus—Parking garage—Outpatient services

01:15:00-01:26:24
Clinton health care reform—Medicare—DRGs—Health care reform—Physician challenges—Reform—Reimbursement

Interview 2 – November 1, 2013
00:00-15:00
Stafford hospital—Initial plans—Growth—Possible locations—COPN—Public discussion—Access—Strategic planning—Presentations—Investment—Board members—COPN—Community—Leadership—Public engagement—Resources—Growth

15:00-30:00
“Greenfield” hospital—Projections—Moving forward—Approval—Construction challenges—Land—Construction—Stafford County—Civil engineering—Planning—New hospital—Staff—Challenges

30:00-45:00
Opening—First patient—Emergency Department—Trauma—First baby—Clinical Provider Order Entry (CPOE)—Growth—Moving forward—Size—Operations—Duties

45:00-01:00:00
Values—Reimbursement—Community Service—Non-profit—Community programs—Community programs—Public health—Coordination of care and health

01:00:00-01:15:00
Free clinics—Moss Free Clinic—IT systems—Hospital administration—Education—Training—Problem solving—Background—Teamwork—Leadership—PR—Marketing

01:15:11-01:31:44
Quality initiatives—Network—Information—Patient care—Primary-care physicians—AMA—Efficiency—Coordination of care—Government regulations—Retirement—Achievements—Future of Mary Washington Healthcare

Transcript

Interview 1 – October 14, 2013

01-00:00:05
Rigelhaupt:
It is October 14, 2013. I’m in Fredericksburg, Virginia, doing an oral history interview with Walter Kiwall. I would like to begin by asking you if you could describe your first day of work at Mary Washington Hospital.

01-00:00:20
Kiwall:
My first day of work was July 1, 1991; it involved an orientation that I attended. I was coming in as a leader in the HR department and I was very interested to hear a lot more information about the organization and the things I needed to know to work within it.

01-00:00:43
Rigelhaupt:
Who led the orientation?

01-00:00:45
Kiwall:
The head staff members from the human resource department led the orientation. A few of the leaders came in and did talks on important subjects, like the care of the patient, the patient satisfaction, the commitment to the organization and to the people that work for it, and work in conjunction with it. It was very interesting since I was coming from outside of the state.

01-00:01:15
Rigelhaupt:
What led you to choose to accept the position at Mary Washington?

01-00:01:19
Kiwall:
I was recruited. I had a recruiter call me and talk to me about an opportunity here in Virginia, in Fredericksburg. I told the recruiter, basically, exactly what I was going to be looking for and for him to give me a call. And it was here; here involved the fact that it was a growing, vibrant community. Many progressive things were happening. It was a health system that was poised to grow. It was a very good place to live. There was access to things and access to metropolitan areas, but far enough away from the metropolitan areas. It had all the things that I was looking for, for my career, and for my family.

01-00:02:20
Rigelhaupt:
What did you see as strengths of the hospital when you first got here?

01-00:02:28
Kiwall:
The main strength of the hospital was that it was poised and interested in growing. Growing in a sense of adding a scope of services, blossoming out into more of a health system, since Mary Washington Hospital had been a community hospital for many years. Because of all the growth in the area, both in population and professional services, all those kinds of things, it was very attractive. I felt that this was an opportunity to grow my career as I grew what could be offered to the community for health services. [03:00]

01-00:03:09
Rigelhaupt:
You began learning about Mary Washington Hospital through a recruiter. What do you remember about your interview, with either the administration or the board, or was it both?

01-00:03:20
Kiwall:
It was mainly with administration at the time. I was not coming into an executive role at the time. So it was with the administration at Mary Washington Hospital. What I remember the most was just the excitement about moving forward, about the growth in the community, the development of good schools, and of a good place to live. Coming from an area of the country that was devastated by the deindustrialization of America, it was good to come to a community that was poised to surge ahead in a different way. It was very exciting.

01-00:03:58
Rigelhaupt:
What did you learn about Mary Washington Hospital’s core values in the interview process?

01-00:04:05
Kiwall:
Values are very important to me. During the interview process—I’ve always taken a position in my professional career that my values are firm: that we’re going to treat people fairly and what you see is what you get. I remember asking those questions. I remember very positive responses to those questions. By the nature of our service and our commitment to the community, there were a number of individuals here, and you could clearly see that deep-seated, good core values were in place.

01-00:04:41
Rigelhaupt:
What are some of the words you would use to describe those core values?

01-00:04:46
Kiwall:
The words, to me, commitment to the community and its mission. To really work on improving the health status of the people in this community. I remember that being strongly said. Sure, we have to make sure all the business is cared for and taken care of so that we can do those things, but what I heard about was we only want to deal with people who deal fairly. If we’re going to do business with people, we have to ensure that their values are consistent with ours. That’s much different than you would hear in many other industries at the time. It was very attractive in many respects, because it was extremely important to me that I join an organization that had the same values that I had.

01-00:05:32
Rigelhaupt:
To make sure that I have your first title correct, you were the director of associate relations and human resources?

01-00:05:39
Kiwall:
Yes.
01-00:05:41
Rigelhaupt:
What did you find to be the most exciting part of the day-to-day components of that job when you began?

01-00:05:48
Kiwall:
The constant interaction with the staff at all levels and with the front line managers. Because the business is about what takes place in the workplace. [06:00] The interest of everybody was in making sure that we had systems in place. The willingness to listen to my ideas and concepts to make sure that we had human resource and associate relation systems in place. That we had a good place to work, that people can grow within it, they were given fair chances and opportunities as they present, and they were treated fairly when things didn’t always go as expected. There was an excitement about that, a willingness to embrace it, and it truly made a difference for me in my first role here.

01-00:06:37
Rigelhaupt:
Who were some of the managers that you first began working with when you started? You mentioned front line managers.

01-00:06:44
Kiwall:
Yes. I worked closely with some of the nurse leaders. Sue Hall, who was one of the nursing directors at the time, she was the connection on the human resources side for much of nursing. I worked with the managers in the lab and radiology, and also in the support services overall. I worked with Mike Jacobs in food service and I worked with Ed Swager in radiology. There were a lot of good folks to work with at the time.

01-00:07:23
Rigelhaupt:
What were some of the challenges that perhaps you could have only learned about once you started?

01-00:07:30
Kiwall:
The biggest challenge was the speed of growth. Organizations get challenged as they get larger. Systems need to change as they get larger. Folks need to make the necessary adjustments. Out of everything associated with the challenges, I would say the speed at which the community was growing and the speed at which we needed to grow to keep up with the services needed by the community.

01-00:08:05
Rigelhaupt:
It sounds like, from what you mentioned in terms of the area that you left, which was de-industrializing—I think it was southwest Pennsylvania.

01-00:08:15
Kiwall:
It was.

01-00:08:17
Rigelhaupt:
What did you see as some of the key differences between—so growth and shrinking, I think, would be one of them, but in terms of the medical facility. What did you see in terms of differences between Mary Washington Hospital and Washington Hospital in Pennsylvania, where you had been working previously?

01-00:08:36
Kiwall:
I think the major differences were the interest in growing scope, breadth, and depth. When I came here everyone knew the population growth was going to continue. All of those things were projected. Everyone knew, also, that as population grows that the scope of service needs to grow. As you know, community hospitals, many times, are community hospitals because there’s insufficient population to support advanced services. [09:00] You want to do a lot of things, and you want to do them well, whatever it is. The main difference was I saw an opportunity that we would quickly be working with a leadership team and a staff to increase the scope and breadth of services at Mary Washington into a regional health system. That was the major difference from where I came from to Mary Washington Hospital.

01-00:09:29
Rigelhaupt:
It sounds as though, in 1991, the discussion to grow into a regional health system was underway.

01-00:09:36
Kiwall:
It was.

01-00:09:38
Rigelhaupt: How was that defined to you as you began working here?

01-00:09:42
Kiwall:
A couple of different ways. There are core services that nearly every community hospital offers. Then there are advanced services in many of the medical and surgical subspecialties, where major types of medical and surgical services are offered that are far beyond what you would normally find in a community hospital. The main difference there was, what are we going to grow into? Where do we have sufficient volume to grow into it? We began to work as a leadership team to define those kinds of things and to bring in open-heart surgery and neurosurgery. We were focused on growing the medical services and bringing subspecialty physicians in. Many community hospitals have specialists, but not a lot of community hospitals have sub-specialists. That became very evident, and it was exciting to be a part of that.

01-00:10:41
Rigelhaupt:
These ideas of growth in terms of developing into a regional health care system, where were some of the ideas of growth coming from? Was it from physicians, from board members, from administration?

01-00:10:59
Kiwall:
Growth was coming from all those sources. Many times, it starts with the medical groups. They see opportunities. They’re sending patients out of town for subspecialty care, they get to see the volumes grow, and they begin to think, “maybe we can recruit this sub-specialist into our group.” They start to have dialogue with administration. It’s also brought up at the board. The board of trustees looks at all of the predicted volumes, the growth in the region, the gaps in care, and the gaps in market share. Many times, the gaps in market share is thought of as a loss to competitor, but it’s a loss of services outside the market due to the inability for the market to provide those services. Each one of those components, at different points in time, would bring things forward. Then we’d do feasibility studies and business plans to see if, in fact, that we did have sufficient volume to offer the service. We all felt very strongly that we could recruit the sub-specialists to the Fredericksburg area because Fredericksburg is a great place to live. [12:00] It’s an easy place to recruit people to. Schools are good here. The infrastructure is good here. The growth is good here. The vibrancy is good here. It’s not a matter of recruiting the talent in; it’s a matter of making sure we have the system and processes in place to get the work done.

01-00:12:25
Rigelhaupt:
At this time, if you were bringing in sub-specialists, as far as physicians, who would take the lead in recruiting a sub-specialist? Maybe an open-heart surgeon. Would it be someone from the hospital administration? Would it be a physicians group? How would that process work?

01-00:12:42
Kiwall:
Typically, you’d get a work team together, a steering committee, because there are clinical knowledge bases that need to be talked about by the referring physicians. In the case of open-heart surgery, it is the cardiologists. What are they seeing in their patients? What do their patients need? What qualities do they believe are important to have in a heart surgeon? We work with our recruiting office, our business development office, and our operations folks. When you start a service, you need to operationally be prepared for it. It involves not only in staff, but also physical attributes and capital equipment, all those things. There are capital purchases involved and there are many components. We bring the OR staff in and we bring the nursing unit staff in. We work together in a steering committee and then ultimately a work group to define the business plan. Then we work to say, “what’s the profile we’re looking for in a cardiac surgeon?” We need a leader because the first one coming in has got to be able to lead the development of program, not just participate in it. It is a much different kind of recruit. All those different profiles were built, and then the recruitment and screening process started. At that time we brought in and began our open-heart surgery program. It was one of the first advanced service programs we brought to Mary Washington Hospital.

01-00:14:05
Rigelhaupt:
The open-heart surgery program opened just after the new hospital?

01-00:14:10
Kiwall:
That’s correct. It began just as we moved in. I believe it’s within a year of moving in the new hospital. 1994 is probably the timeframe.

01-00:14:24
Rigelhaupt:
I’ll come back to that as we get to the new hospital, but I want to stay with the first couple of years before the new hospital opened. What was your first impression of the staff, particularly nurses, when you began working here?

01-00:14:40
Kiwall:
I was seeing more nurses also poised to do more subspecialty work. As health care gets more complex and complicated, there is more of a need to have subspecialty focus for our nursing staff; and they were interested in going there. They were interested in getting into the open-heart program, getting into other things that they had learned in their various training settings, or where they had previously worked. [15:00] We had the luxury of having a lot of spouses tied to the military. Many of them are nurses that have worked in other places, worked in medical centers, worked in advanced centers, and where they were bringing those types of skills here. We had the benefit of the demographics of the area helping us as well.

01-00:15:30
Rigelhaupt:
Was this something you began to plan, or you, as part of a team, even before the new hospital opened, that you were going to increase either the education, the training—I’m not sure if I’m using exactly the right word—particularly on the nurses to bring in these programs? What’s the process for that?

01-00:15:50
Kiwall:
There was a lot of talk. I got here in ‘91. The land was being cleared and the hospital was being built. Of course, the primary focus was to get the hospital built and get the hospital moved to the new site. A lot of work was being done on that for the first year and a half or so that I was here, just to get that done. Everybody realized at the time that the new building was built for and positioned to be able to advance the services. It gets back into that discussion. We had been talking about open-heart surgery, and felt that it was the first one. Then where do we need to go from there? Do we need to get into neurosurgery? Are there enough transfers in neurosurgery? Should we be getting into more of the surgical subspecialties, the general surgical subspecialties that we brought in? More and more of that was taking place. The physicians were beginning to focus on particular areas, and they were recruiting physicians who did fellowships in subspecialty areas. We started to see more and more of that. There was more delineation of the services that various specialties offered, in an effort to advance them and to bring the highest quality to the community. Those talks began fairly soon. I don’t know that we were moved in over to the new site —hardly the paint on the wall was dry—when that discussion continued to take off.

01-00:17:20
Rigelhaupt:
What was your first impression of the physician community?

01-00:17:24
Kiwall:
My first impression was a good one. Once again, because of growth, there was a good mix of physicians that were well into their career, mid-career physicians. And then the younger physicians were being recruited in at the time. Once again, most of it was driven by growth. All the groups who had been in the community a long time have expanded substantially, particularly specialty groups. A number of the primary care groups have expanded. It was exciting to see that there was a physician community interested in moving things forward, not just in staying in place. [18:00]

01-00:18:03
Rigelhaupt:
What was your first impression of the administration?

01-00:18:07
Kiwall:
My first impression of the administration was progressive. It was a huge decision for the board and the senior executives here to make a decision to build a brand-new Mary Washington Hospital, ninety-plus acres away from the current building. That told me that they were willing to move forward. It wasn’t stay-in-place and keep trying to tack onto an old building and tear a wing down and build a new wing; what I call the staying-in-place facilities. I was a lot more excited about moving forward and creating something more advanced for the community.

01-00:18:52
Rigelhaupt:
In particular, what did you see as some of the strengths that Mr. Jacobs had and was talking about as CEO of MediCorp when you began?

01-00:19:04
Kiwall:
Not long after I got here, probably within a year, I started to work more closely with Mr. Jacobs. The executive vice president of HR at that time left for another position. I was then promoted to interim vice president. At that point, I began to interface regularly with senior executives, and particularly with Mr. Jacobs. By that time, Mr. Rankin was here as well. I spent a lot of time with both of them. With Mr. Rankin, we were talking about all the services that could be added in the facility. With Mr. Jacobs, we were talking about creating a regional system that would go even beyond the walls of the hospital, to take the care to the people. It was clear to everyone that the roads structure was at a place where everybody just couldn’t get to a single place at any given time; and it didn’t look like any of that was going to get resolved soon. It was different things with both of them, but at the same time, very complementary.

01-00:20:13
Rigelhaupt:
What did you see as some of the key areas that Mr. Rankin, as president of Mary Washington Hospital, was talking about in terms of growth? He came in ‘92, but still, about a year before the new facility opened, so there was time to talk in more hypotheticals, I guess.

01-00:20:35
Kiwall:
Mr. Rankin brought broad depth of experience from a large tertiary care center in the Pittsburgh region. All the things that Mary Washington could grow into, as far as scope of services and how it would be done, he had experienced and been part of for a good portion of his career. He worked in large systems, both in the North Hills of Pittsburgh and also in the area around the University of Pittsburgh. [21:00] He brought the experience. He brought experience with the type of services that we could grow into. As we began those discussions, he was a great resource and he knew where to get answers for questions that we had. It worked out really well because of his recent experience and his interest and willingness to grow Mary Washington Hospital.

01-00:21:34
Rigelhaupt:
This is not an open question, but you had come from a smaller hospital, and I don’t know if the ratio was about where it is now, where Mary Washington Hospital is about twice the number of beds as Washington Hospital. If that was about the ratio.

01-00:21:49
Kiwall:
About that, yes.

01-00:21:51
Rigelhaupt:
So you’d come from somewhere smaller. Mr. Rankin had come from somewhere larger. Were there things, based upon where you had worked in terms of the size of the facilities, that you might have approached problems or challenges differently?

01-00:22:11
Kiwall:
I don’t think so. Yes, the hospital I came from was 200-some beds, and Mary Washington, at the time, I think, was 350 and went to 435 or 437 later. But I didn’t see a lot of difference in that. It was the energy to get it moving, to make it happen. The new faces were vibrant and willing to move things forward. It was very different than the area I came from, where people got jobs and stood in place for their entire career. There was an energy here that was different. That seemed to make the difference in growing Mary Washington, which is now the second-largest hospital in all of northern Virginia, in both size and scope. I could see that potential at the time.

01-00:23:09
Rigelhaupt:
When you first started, it was a large—as you said, ninety acres were being cleared. The new facility was being built. Did you hear or participate in any conversations that recognized that any change, or particularly the size of growth, represented some risk? What did you as an administrator and your colleagues see as some of those potential risks?

01-00:23:39
Kiwall:
The risk when you invest in such a large facility, and the cost of such a facility, you’re definitely banking on the growth in the business to be there. Even though there was risk to it, and there’s risk to every decision, no matter what it is—there’s no guarantees. [24:00] There was no indication that the growth in this region was going to slow down. The population growth, the support and new services, and the support of the federal government: there was no indication whatsoever that it was slowing. As a matter of fact, every indicator was predicting that it was going to continue. Although there was some risk, I think, in a pure business sense, the risk at the end of the day was minimal. The bigger risk was to stay in place and not be able to meet the needs of the community. The bigger risk was to let this building that we’re sitting in now be overwhelmed with patients and not have the ability to take care of them. Which to many, I think, was a greater risk than moving into a facility that was poised to care for more patients.

01-00:24:47
Rigelhaupt:
I can see the clear risk more even just in the sense of not fulfilling the mission. If the hospital allows itself to be overrun, to not be able to provide the health care that the community needs. What happens, I guess is what I was trying to say. What happens to a hospital if it doesn’t grow and it allows itself to be overrun or not be able to provide the health care to the community?

01-00:25:39
Kiwall:
The greatest risk to any business is not being able to take care of the folks that need it, whether it’s a product or a service. Once that failure gets out, if in fact it happens, then it will create a situation that will be the demise of the business. If you don’t take care of the people you serve, or the product that you produce, then, in fact, someone else will. Also, in this community, since there’s distance between Fredericksburg and other parts that have facilities, it would mean that people wouldn’t be served. Unlike a product or a service that we can elect to have or not have, health care is necessary for every single one of us. Anytime in our careers or our lives or lives of our family it’s necessary. We comfort many people every day at the hospital in the last days of their lives, and we bring many into this world on the first day of their lives. We have to be there to do that. We can’t slough that off to a different day. We can’t say, “Come back next week.” Those are all things that are very different from the nature of the service that we offer the community. It becomes crucial that we’re always able to care for those who come to us. [27:00] The other thing that hedged the risk was, with the population growth, it’s not just doing more of the same things you do. It opened up the opportunity to do new things. That hedges the risk even more. Where if you didn’t make the move, you didn’t have the physical capabilities for caring for people, and you do not have the ability to move and enhance what you’re doing to take care of more people. At the same time, people get disenfranchised with the services that you offer because you can’t offer them in a timely manner. We all know that when our loved ones need health care, it isn’t tomorrow, it isn’t the next day; it’s when it presents itself. It is a very different obligation as a business than most businesses have.

01-00:27:50
Rigelhaupt: When you started here, was there discussion about some of the success or challenges that some of the ancillary facilities had already faced, in the sense that, in the mid-1980s, moving out to Dahlgren, Bowling Green, and North Stafford, Mary Washington—or MediCorp at the time—had opened these. What did you hear about that, I think, smaller-scale growth into a health care system? And where it was working and where there were some new challenges?

01-00:28:29
Kiwall:
I was hearing a lot of positive feedback related to it, because without the outreach, without the additional points of access, then everything had to be funneled to the campus. In some cases, you’re funneling patients, because they have no other choice. They need the care now, to the level of care in the hospital? That they don’t need. Of course, bringing too many people into a level of care, like an emergency department, that shouldn’t be there, only because they don’t have access to other types of services, creates a strain on the entire system. It creates the opportunity for things to be delayed for patients that shouldn’t be. We were hearing more positive feedback about the fact that we were placing health services more out in the community so that we could improve access and take some pressure off the advanced systems at the hospital.

01-00:29:26
Rigelhaupt:
Was this an early example of MediCorp trying to bring primary care to a broader scope in the region?

01-00:29:38
Kiwall:
Yes. We spend a lot of time recruiting primary care physicians. We do a medical staff development plan, which is reviewed every year. Primary care was job one, job two, and job three at the time. The growth was putting a lot of pressure on the need for primary care. We worked with a lot of the independent groups in the community to find ways to assist them with recruitment. [30:00] We used various techniques. We used our own recruiters. We put programs in place to assist them with recruiting physicians into the community. It was absolutely necessary in order for the community to have the right kind of access, so we spent a great deal of time on that. We brought a lot of physicians into the community. Then that, in turn, caused more need for specialists in the community. We spent years and years with medical staff development, working with a lot of the independent practices and community, to grow and to add additional sites. In the last twenty-two-plus years that I’ve been here, a number of the physician offices and businesses have added sites. They’ve got two, three, four, and five sites. When at the time I arrived here, they had one site. We worked with them a lot about access, so it really made a difference. Then urgent care began to come in the community with NextCare and Patient First. That started to take care of some of the urgent care needs. Until that point in time, we had very little urgent care access.

01-00:31:15
Rigelhaupt:
In the first couple years you were here, it sounds like a period of pretty fast growth. Could you walk me through a kind of step by step of how MediCorp and the administration would support recruiting a primary care physician?

01-00:31:34
Kiwall:
Step one was to develop a medical staff need. What were the volumes, the access to current resources in the community? We would develop a medical staff plan. “We need 9.2 primary care doctors, three cardiologists.” There are methods to do those things related to populations. That was step one. Let’s identify what the need is. After identifying what the need is, then we began to engage some of the local groups and talk to them quite extensively about their interest and opportunity to grow. We talked about how could we help them. We saw a need to have the additional physician resources in the community—the first line of addressing it was always to go to the existing groups. We went to the existing groups, worked a lot with them, began the recruitment process, assisted them with screening, and worked to ensure all the credentials were in place. We did a lot of that work with the groups. We brought in candidates, multiple candidates, for a number of interviews, and then began to assist them with placement. As you walk through it, that’s how the general process works. We’re putting our time and effort in physician specialties where they have the greatest need. That’s pretty much how we did it from the beginning to actually getting the physicians here. [33:00]

01-00:33:02
Rigelhaupt:
But at this stage, most of the physicians would have ended up in private groups, and with admitting privileges to the hospital, not as employees of Mary Washington.

01-00:33:15
Kiwall:
Right. We still have that today. We have a fairly small group of employed physicians. This medical community is interested in maintaining the private practice model, and we’ve worked with them to do that. Now, there are specialties that we have and that we had to employ because a private practice model in community was not going to work. For the most part, that’s what we brought in and employed. We worked with existing independent groups to screen those physicians and to make the recommendations even on the employed physicians. We would make sure that they have the right relationships and the referring physicians were comfortable with their skill sets and the communications style and skills. All those were put in place. We simultaneously worked on bringing the needed specialists in that would not work in a private practice model. At the same time we were bringing physicians into the independent private practice model to be considered for being employed or a partnership with them.

01-00:34:18
Rigelhaupt:
If I understand correctly, there’s also a long history of tension between hospitals and physicians groups in terms of growth and potential for business. As part of the American health care system, there is some tension. In those first couple years you were here, were there any areas of tension that came up between MediCorp and the physician community?

01-00:34:43
Kiwall:
There wasn’t a lot, primarily because the volume pressures on nearly every practice outweighed any concerns about loss of market share. It was growing faster than anybody could keep up with it. We really didn’t have much tension between us offering something and the independent groups offering something. It was actually very collegial. Growth with them was very good. For the most part, we only got into specialties that they weren’t in and they weren’t working in in the community. Except for programs like trauma and some of the other ones where you need dedicated in-house staff, we continue to work with the local, independent physician groups and maintain a good relationship with them the whole time. It’s still true today.

01-00:35:40
Rigelhaupt:
Just for the interest of comparison, was that different than where you had just left at Washington Hospital, where the population was shrinking? Was there more tension between the hospital and physicians?

01-00:35:54
Kiwall:
There was, and I think that tension was built on the fact that volumes were not increasing. [36:00] Many times, reimbursements were continuing to be cut by bundling or other methods. It appeared that many of the physician groups were looking into getting into some of the services traditionally that were offered by the hospital. Things like outpatient surgery and other things, like cardiac nuclear SPECT cameras—all those things were not considered physician services, but ancillary services. There was a little more tension with that. That is all driven by the need for individuals to get into various service lines that they would have not traditionally gone into if there had been sufficient volume.

01-00:36:54
Rigelhaupt:
Thinking about your first couple years, and it sounds like it was your first year you were director of associate relations and HR, and then became vice president. Or maybe an interim—

01-00:037:04
Kiwall:
I was interim for a short period of time. Probably within two years of getting here, I was vice president, yes.

01-00:37:11
Rigelhaupt:
So thinking about those first couple years, and maybe even thinking of trying to mark the opening of the hospital as a kind of before and after point. But like all administrators, your job is charged with patient care, even though your hands are not directly on patients. What were some of the things that you wanted to see happen in some of the departments that you were leading, and what were some of the strategies you employed to make changes that would ultimately benefit patient care?

01-00:37:46
Kiwall:
Personal growth in a professional sense. As a business becomes greater and begins to offer more, the individuals associated with it need to also have the abilities to offer more, to do more, and to keep things in house. The first few years I was here, we spent a great deal of time on professional development of staff. It was interesting to talk to staff. It involved everything from the nurses getting their specialty certifications and their advanced degrees to our own engineering staff getting certified or registered in the various trades that they were in. We’ve got very sophisticated plan operations in all of our facilities. It was an exciting time of what I would call professional development, and then recruitment. We were bringing people in who had particular skill sets. We were marrying them up with long-term staff who had not spent much time involved in those kinds of services. It was a good time of growth and development. That was the fun time—the first few years I was here—related to watching the staff grow into their professions, and assisting them to do that. [39:00]

01-00:39:08
Rigelhaupt:
It sounds as though that’s a pretty significant investment in the people of Mary Washington Healthcare, or MediCorp at the time. How do you find the resources to make that kind of investment?

01-00:39:24
Kiwall:
When you do the analytics—if you don’t grow and prepare people to get to where they need to be, the cost of recruitment gets overwhelming. It is expensive to recruit somebody; to spend all the time and effort getting them here, and they leave shortly thereafter. If somebody is leaving, other than for a life change or need, then there’s an extreme cost associated with that. When you do the cost-benefit analysis and return on investment, working with staff to get them the education and training, to financially support that education and training, and for them to give a commitment to the organization to stay was a much better investment than trying to constantly deal with the turnover. Then we had some folks who had worked in the organization for quite some time. They wanted to continue working in the organization, and they were interested in growing. We know that when we invested in them—they had been here for years—if we invested in them, they can feel better about being prepared for the future. They would stay and they would be able to do their jobs in the way that we needed to have them done.

01-00:40:34
Rigelhaupt:
Based on what you’ve said about the level of growth the first couple years you were here, is it safe to say that the financial climate of MediCorp and Mary Washington Hospital was also experiencing growth?

01-00:40:48
Kiwall:
Sure. The volumes here were going up constantly. The demands on processing of all those things, whether it was direct service or whether it was entire processing of everything necessary for a person’s experience, that demand was there as well. The strain was there as well. In any business, growth is a good problem to have. At the end of the day, that’s very solvable, as long as people have enough insight to look at the future and understand the time to get there.

01-00:41:30
Rigelhaupt:
That’s certainly one of the things that we hear about a lot now, and I don’t mean to use contemporary language looking backward, but certainly the cost of health care is something that’s obviously a part of the country right now. At this period of growth, was there also discussion about needing to control cost, or was that not as present in that first couple years you were here? [42:00]

01-00:42:02
Kiwall:
It was not as present. The challenge was to be able to care for those presenting a lot more. Of course, we didn’t have technology. We didn’t have flow of information, not like we have today. You didn’t have the ability to, as we say, connect all the dots. That ability is changing now. We’ll be able to have a lot more effect on efficiency and effectiveness and ensure that there’s no duplication and waste today because of the flow of information. Back then it didn’t exist. The challenges in the first years were to get the resources in place to care for the patients, stay on the development of health care trends, and that’s pretty much what we focused on back then.

01-00:42:51
Rigelhaupt:
Some of the changes that had happened in the previous decade, in terms of hospital reimbursement, DRGs, those were attempts to control costs. They were not having as big of an impact in those first couple years you were here?

01-00:43:06
Kiwall:
No, they didn’t, because at the same time that was going on, the advancement in health care was taking place. There were a lot more services to be had, to help with your health and well-being, or to save your life. Of course, with every new service, there’s a new cost. As things advance, costs advance with it. Now we’re able to do things to folks for their better overall health and to keep them healthier, but there’s also an additional cost to that. There were a lot of leaps forward in the first ten years, related to the types of things and services people can have in order to improve their health. That challenge, in the last five years, has become a new challenge. But back then, it was more of, are we offering everything that you should have access to, to make your health better or to save your life? That’s what people were looking for at the time.

01-00:44:14
Rigelhaupt:
Let’s switch to the new Mary Washington Hospital, even though it just celebrated its twentieth—I’m not sure what number it will have to reach before I stop calling it—

01-00:44:23
Kiwall:
The new.

01-00:44:25
Rigelhaupt:
What do you remember about either seeing the construction site during your interview, and what were some of your initial thoughts about what this facility was going to represent?

01-00:44:36
Kiwall:
It was amazing to me that they could find about ninety-five acres in the middle of a city. I’ve never heard of such a thing. Although the Snowden track up there was maintained for all those years. It was easy to see that they had the geographic space to meet the needs for the region. The campus was clearly big enough that it wouldn’t outgrow some city street that’s around it. [45:00] That was exciting. The elevators towers are usually the first things that come out of the ground. That’s the concrete that’s poured and the first things that are built. We got to see those coming out of the ground; it was exciting looking at the plans. I was given operational readiness responsibilities at the new facility, so that when we flipped the switch up on the hill it all worked. I spent a lot of time looking at that. I had a lot of process and engineering background and they assigned me to that not too long after I got here. That plugged me in. They had a much larger group that was in charge of getting all the clinical things, all the staffing figured out, and all of those kinds of things done. A totally different group was working on that. Mine was mainly, is the facility to do what it needs to do and is everything going to work there? We had to make sure all systems were go; everything from the tube system, to HVAC, to all the lights, to the emergency power, to all of those kinds of things that nobody thinks of unless they’re not there. It was exciting to use some of my engineering skills, to get into looking at the drawings, looking at the fail-safes, looking at the facility, access to the facility, access to doors and security, and all those kinds of things. It became exciting because it was a brand-new hospital, and I had never been involved with a brand-new hospital before. Later on in my career, I got a chance to do that again in a bigger way since I had that experience to some degree. It was very exciting to see it come out of the ground, as modern as it was. I always say that old hospitals look like prisons or schools, but this was a modern facility. Even today, as you look at it, I would put it against any facility. You will never think of it as the old hospital because it sure doesn’t look like the old hospital in any degree, even after a design that’s twenty-five years old at this point.

01-00:47:13
Rigelhaupt:
What were some of the unique challenges of being ready to have everything work when the switch got turned on, and running a facility that was operating?

01-00:47:29
Kiwall:
The biggest concern, for me, it wasn’t what I call the mechanics. The plugs are going to work and the water is going to come when you turn it on. The heat and the air conditioning are going to be there. Things are in place and it wasn’t that. The biggest concern was the fact that there was nobody moved in that building that had inherent knowledge of it. There was no legacy. There was no associate who’d say, “I know where that is.” You could find somebody here who had worked in this building for twenty or thirty years. [48:00] If you wanted to ask them, “Where do I go to get this?” or “Where’s this part of the building?” They could take you there and they could tell you every detail. The trouble with going into a brand-new, extremely large facility is there’s no knowledge base with any individuals. When somebody needs something or to know where it is, and being able to turn around and ask somebody—they may not know either. Someone might turn around, ask somebody, and they not know as well. That was the biggest concern I had and I couldn’t resolve that. We had a lot of guidance things put together and templates to give to staff. We walked staff around. I had them kick the tires, so to speak. We spent a lot of time before we moved in getting people familiar with the building, since nobody had that legacy. That was my biggest concern, that something would be needed and nobody would know where to get it or how to get it. That’s something you never have when you go into an existing facility and has staff with many years of experience.

01-00:49:15
Rigelhaupt:
Do you remember anything that came up where someone couldn’t find something in those first few weeks or months that it was open, that you couldn’t have anticipated?

01-00:49:28
Kiwall:
I think people were pretty good about understanding what I call the critical resources. I do remember getting on an elevator with a long-term associate in our organization. They had worked here for more than twenty years. I said, on the elevator at the new facility, the first week we were there, “How do you like the new facility?” “I don’t know,” she said. “What do you mean, I don’t know?” She goes, “I don’t know where anything is. People used to come to me and ask me where everything is.” This person had lost part of their perceived value. This particular lady had a job that moved her around the hospital. I said, “You give it a couple months. They’ll be asking you again and you’re going to know where it is. Because you want to know where it is, don’t you?” She said, “Yeah, I do.” I said, “In a couple of months, moving around a building, asking the right questions, and observing, I’m sure you’ll be that person here shortly.” And she just smiled and got off the elevator. Those moments with staff and the excitement of something new, but the uncertainty of what it means to them personally. It is something you just have to understand and you’ve got to work with overall. But as far as did anybody not know where something is, for the most part, we had enough people around from the building construction trades for a long time. [51:00] Particularly when it came to facilities—”Where is the switch for this?” or “How do you turn that off?” or “Why isn’t this working?” Overall, I think we had a pretty good resolve for almost all of that. I can’t point to a time where we couldn’t find the answer in a reasonable amount of time. We understood that gap and we had to make sure that we had resources on call that we can get to, and we did.

01-00:51:34
Rigelhaupt:
Even before it opened, what do you remember about the first—you said you brought staff over. There was a lot of walking around, becoming familiar. What do you remember about seeing how they reacted to the space? What do you remember about conversations you had on those tours about what it meant to begin to work in this new facility?

01-00:52:00
Kiwall:
The biggest thing I remember is the staff recognizing they now had a bigger area to work in. In our business, if you’ve watched it over the years, hospital-sized rooms and hospital-sized ORs, they’ve gotten bigger and bigger and bigger. The equipment going in those rooms has gotten more extensive. The services offered in those rooms have gotten more extensive. As technology took leaps forward the building [2300 Fall Hill] didn’t stretch. The old hospital buildings didn’t stretch. We got very cramped in many of the areas. What I remember the most about the staff was feeling good about the space. Now we’ve got room to put this machine, this machine, and this machine against the wall. Where we’re at now [2300 Fall Hill], we’ve got to put two or there and one over here. It’s like going through a maze of wires to try to get between them. It was the excitement of a larger space and state-of-the-art equipment. That was the excitement I saw in the staff more than anything.

01-00:53:07
Rigelhaupt:
And, of course, you and others had to have recognized that you weren’t going to build another facility in ten years, and so you’re really trying to imagine ten, twenty, thirty years out. What were some of the conversations you remember having as it was opening, even trying to think about what might go in here in a decade or two?

01-00:53:33
Kiwall:
I asked a lot of those questions. Once again, with growth, there’s a point in time it looks like it’s going to meet it. Well, guess what? It’s still going. I was very happy and pleased to find out the building was constructed to be added onto, both vertically and horizontally. It was exciting to see the structure of the building and the way the elevators were put in place. We did the same thing at Stafford; in fact, it was meant to be built on. [54:00] That gave me a level of comfort, and there was enough space around the building that we can build onto it. Of course the hundred-bed tower we added in 2004 is an example of a massive construction project that changed the whole complexion of the hospital, as well as adding the additional beds involved. Overall, it was good. It was good to hear that there was enough thought put in the project to say, this is built to expand on, unlike the older facilities that weren’t. If you’ve been in old hospitals, you’ve got to get off this elevator and then go on a different elevator. The reasons for that is they were not made to be built on. That is not the case at Mary Washington. You still get on the same set of elevators, and they take you everywhere you need to go, even though the building’s been expanded. In an engineering sense, it was exciting to see that that thought had gone into the whole design. It was very good to see.

01-00:55:00
Rigelhaupt:
So, a decade in, 2004, a new hundred beds opened. Was that about growth and, for lack of a better term, just regular hospital beds, or were those beds in the addition designed to support new and specific services?

01-00:55:20
Kiwall:
They were designed for new and specific services. In 2002, we opened a new emergency department up there. There was a need to move towards more advanced services and a need to move towards trauma. We built the new emergency department and we included trauma rooms in the emergency department. That freed up the old emergency department area to expand imaging, get into advanced CT scanners, and all the things necessary to handle trauma patients. The hundred-bed tower that we built in 2004 also included brand-new, state-of-the-art intensive care units. There were new intensive care units built up a floor. We had intensive care units and we could take care of the sickest patients. There was enough equipment in place, and the right types of equipment. We recruited the staff. As we worked on and built on the expansion, it was not only the expansion to deal with the additional patients, but expansion to deal with additional scope. The ER, radiology, ICU, and then future ORs were changed as well, over the last five to seven years. All those things were done to meet the expansion of services, as well as any type of expansion of growth. It was very systematic in how the different elements were added to the hospital and to make it the advanced tertiary care center that it is today. You can get there from here, and it all works. All the flow works, and our staff has got the resources they need to care for the patients. [57:00] We were truly transforming into a tertiary care center at the Mary Washington Hospital, basically from the day we moved up there. The writing was on the wall that it was positioned to do that.

01-00:57:14
Rigelhaupt:
By 2004, were you the chief operating officer?

01-00:57:19
Kiwall:
It was close to then, I believe, when I took over that role. I always had responsibilities for the physical expansion of things in the organization since I got here. For the current project at Mary Washington Hospital, I was here when it was already started. But all the additions, and all the additional resources and facilities that we have, including Stafford Hospital, that was all under coordination between myself and others.

01-00:57:55
Rigelhaupt:
Thinking about what went on when involved between 2002—if my notes are correct, it was a doubling of size of the emergency department.

01-00:58:06
Kiwall:
It was.

01-00:58:07
Rigelhaupt:
And putting in trauma rooms, imaging, new ICUs, new ORs. What’s harder, planning the physical in terms of all the equipment, the space, making sure there’s a flow, as you described, or, and then, of course, bringing all the people involved? What presents more challenges?

01-00:58:35
Kiwall:
I think they’re different challenges. I think programming is the greater of the challenges. Although our construction is very complex because of regulations. Constructing things physically—there are a lot of twists and turns in it as well. But at the end of the day, the most important piece is the programming. How do we put the systems in place and the people in place to deliver the service? That’s where our clinical people really stepped up to the plate, worked on recruiting, and worked on development, as I said earlier. All those things were happening, as we were beginning construction, with the idea that when construction was completed, the programming would be ready to go. We had both things happen at the same time.

01-00:59:23
Rigelhaupt:
Was the plan, already in 2004, to begin—or was it already underway—to truly plan a trauma program?

01-00:59:33
Kiwall:
It was. We were putting pieces in place all along. We put a blood bank in place and the lab as well. It was one piece at a time, what I call the physical aspects of trauma, getting those all in front. Then Marianna Bedway, at the time, took on the programming for the trauma program. That was right after we had completed all the physical changes we needed to do. [01:00:00] It was thought that we would get there. The state had recognized that the area needed a trauma program. It was in a state plan. They had been talking with us about that. They had put it in the plan because we needed something between northern Virginia and Richmond. We worked close with the information given to us by the state, and worked with our own staff to get it in.

01-01:00:36
Rigelhaupt:
How about if you could explain, why does a trauma program need the physicians to be employees versus in a group?

01-01:00:45
Kiwall:
The principal reason is the nature of the work. The trauma program work is in the house. You have to have on-call, in-house physicians, both for trauma surgery and for the intensive care unit. It’s a special type of individual that you have to recruit. Typically, you don’t see trauma surgeons and a general surgery group in the same group, because they are different professions. Even though many of the general surgeons can do the surgery aspects of trauma, of course. Trauma surgeons also do the intensive care unit aspects. We didn’t have a group in town that was interested in—nobody was interested in starting a trauma group in town. It made sense for us to bring them on and employ them ourselves.

01-01:01:34
Rigelhaupt:
What was the process of recruiting? How does that work?

01-01:01:39
Kiwall:
The programming was complete. We worked with some consulting firms and with one of the local general surgeons, who had assisted us from the beginning. All general surgeons do trauma rotations on the surgical side. We worked with him. He helped us to develop aspects of the program. Then we brought a consulting firm in. They worked with Marianna Bedway and other members of the team to get the trauma programming done. Once the programming was done, then descriptions for each individual were completed, including the director of trauma as well as the trauma surgeons. We developed all the credentials and identified the credentials necessary to do these programs; there is usually an ICU fellowship that’s involved with the trauma surgeon. Job one was getting the director in, somebody who had been at that level. Then we would work with the director to recruit the remaining trauma surgeons and extenders.

01-01:02:44
Rigelhaupt:
Who was the surgeon in town that assisted early on in the—

01-01:02:49
Kiwall:
Dr. Richard Earnhardt from Surgical Associates of Fredericksburg assisted us with the early development of all the resources needed for the trauma program. [01:03:00]

01-01:03:01
Rigelhaupt:
Previous to that, were there general surgeons always on call in the emergency department?

01-01:03:07
Kiwall:
Yes. We had general surgery call, but when trauma would come in, it would usually be flown out. Many times, it was flown out from the scene. They don’t even get to the ER. In the ER, it was also flown out because it’s more than just the surgical skills. It’s the blood bank, it’s the resources necessary in the OR, and it’s the in-house call team that has got to be made available. When you don’t have those resources, because you’re not a trauma program, you can’t handle those patients. You can’t care for them timely manner, and you can’t get them to the resources they need. Typically, out of most hospitals, they’re flown to trauma centers. That was the difference. We did have general surgery call. When it came to trauma patients, they were stabilized and transferred, if they made it to the emergency department at all. Many times, the choppers would take them directly from the scene.

01-01:04:01
Rigelhaupt:
I want to go back to when the new hospital opened. Could you describe what it was like to walk through the new facility, the end of the day, when the 150 or so patients had been moved in and, for lack of a better term, it was alive?

01-01:04:26
Kiwall:
Exactly. Hours before we started to move, it was a polished-up, good-looking physical plant. But you looked up and down the halls, you didn’t see much. You looked in rooms, you didn’t see much. I got to experience that, too, at Stafford, as we were getting ready to open it up. It was very different. You look. You say, “We’re ready.” Then, for the whole transition, it started to take place. By the end of that day, it was alive like it had been there forever. People were moving in the hallways. They were going in and out of the patient rooms and taking care of the patients. They were excited about being in this brand-new facility. There was a level of energy that was there, and it was like, instantly, the hospital was alive. The individuals involved were all making it that way. They were all helping each other. “Hey, do you know where this is?” “Do you know what floor this physician is going to be on for his type of patients?” They were excited about working with each other to make it happen. I was truly amazed how, once we got all the patients transferred and in place, how it looked like it had been there operating forever. It was alive and well. If you know anything about hospitals, this is twenty-four/seven; it’s never down. It was exciting to see the staff doing everything they needed to do to care for the patients. It was a great feeling. [01:06:00]

01-01:06:10
Rigelhaupt:
It sounds as though, based upon the planning, both in terms of what happened, when it opened in 1993 and over the next decade, that the new facility was poised to provide new services and provide a higher level of acute care. And at the same time, as we talked about previously, there’s also part of Mary Washington Healthcare, MediCorp at the time, was about primary care and health care in the facility, and in the region. How did this new facility, in that first decade, make it possible to expand also into primary care and health care in the region?

01-01:06:59
Kiwall:
The strain was being developed on the primary care physicians. They cared for the patients in the hospital, not just in their office. The extreme volumes of patients, and the phone calls to primary care physicians to come in, were getting very taxing. We had to find a solution. We started the solution by having nighttime hospitalists on to begin with. There were three or four of them that I spoke to. I was in this administrator’s job over there at the time. Primary docs needed some nighttime relief. They were saying, “You can’t keep calling me at two o’clock every morning, and then I’ve got to go in, and then see my patients during the day.” That’s what was happening because the volumes were so great. The first relief on the primary care physicians became the transition to hospitalist services. It started with a term we called a “nocturnist,” the original hospitalist on the night shift. It was a new term that got coined in our industry, and that’s how the hospitalist movement began. Then it morphed into twenty-four hours a day as the pressures in the office and the need for the primary care docs to be in the office took place. It was fortunate for us that the transition did take place because our primary care physicians were getting way too strained in the community. They were in and out of the hospital day and night, and it was getting to be extremely difficult for them.

01-01:08:36
Rigelhaupt:
And this was one of the ways that the hospital system, or the health care system, could provide assistance to the physicians, but also this wouldn’t create tension. This was about working in a hospital overnight.

01-01:08:50
Kiwall:
It was. We did it in conjunction with our primary care physicians. It also meant that there was going to be a primary care physician in the building all the time, for the most part. [01:09:00] The advantage to patient care was access up on the floors to a physician immediately. We had ED in place for many, many years. It was basically now patients had access, in the middle of the night, to primarily internal medicine physicians. They would have had to be called in before, to get them in, or to talk to them on the phone, to decide whether they need to come in, to give orders, or do those kinds of things. It worked out for both parties on the night shift. The patients have access, and the primary care physicians have that relief.

01-01:09:51
Rigelhaupt:
We talked a little bit about the growth of the hospital, adding a hundred-bed wing. Were all the facilities that are physically on the campus, from Snowden to the cancer center to the women’s center, the surgery center, even Kaiser—were these imagined as—in some ways, if you can parse your couple years before it opened, and then in the immediate decade after the new hospital opened.

01-01:10:26
Kiwall:
The growth of physician offices on the campus developed over time. When we moved to Mary Washington, the road was not up through the campus. It ended at the hospital for years. The vision was to use those lots for physician practices. That was in place in the original design. The movement of the surgery center to the campus from down on Princess Anne, that developed as the surgery business started to take off. It was recognized we needed to build an ambulatory services center building that we could put in both outpatient surgery and outpatient imaging at the time. The campus was designed to add different services, so it worked out really well. Of course, we had the hospital and the medical office building attached to it. Then we created a street and put the ambulatory services center building in, knowing full well that that’s part of the transformation in health care; where much of the outpatient services began to leave the main building so that the main building can be more focused on patients needing inpatient care. You can get the patients in the right setting at the right time, and ensure that the building doesn’t get overwhelmed with volume. Because now you’re moving volume out that would have been there, possibly being in the way of acute care services needed. It was a nice transformation, but it was nice also to have ninety-plus acres of ground to do it with. [01:12:00] It all worked out really well. Then parking became a challenge. We had to build a thousand-space parking garage at the time, because it was evident that we had more and more ambulatory services coming to the campus, as well as the growth of the hospital. As you can see today, there was space for it. It was put in. As it grew, various infrastructures were added, and it was able to keep the pressure off of Mary Washington much longer. That was until we got to a point where the emergency department was absolutely full as we were getting ready to open up Stafford Hospital and the freestanding emergency department. It was very good for us to move in that direction so that we can use the best resources in the hospital, and use its assets to take care of the acute care and trauma patients. It worked out well.

01-01:13:00
Rigelhaupt:
As we also talked about earlier, there’s, of course, concerns about finances, reimbursement. Is ambulatory outpatient surgery, all of this, does it create similar in terms of growth, or a similar financial climate, as the acute care, in-house patient care that had been here for ninety-plus years by the time the new facility opened?

01-01:12:30
Kiwall:
The outpatient arena is a more effective and efficient use of resources to do those services, whether it’s imaging or outpatient surgery. There’s no question about it. What it did is take the hospital back to its core: to be a building that you go to for emergency reasons or you go to when you need to be there overnight or more. I think that’s worked out well. Separating the imaging and outpatient surgery made it more effective and efficient. Even though reimbursement is lower in the outpatient setting, the effectiveness, efficiency, and care of the patients turn out better overall as well; it becomes a win-win for all involved.

01-01:14:20
Rigelhaupt:
So there had already been an outpatient surgery center. It was really just a decision to bring it to the campus?

01-01:14:25
Kiwall:
That’s right. The decision was expand it and bring it to the campus. Same thing for imaging—we had a small imaging presence on Princess Anne as well.

01-01:14:40
Rigelhaupt:
Also about the time that the new hospital opened was the potential for health care reform that happened under the Clinton administration. A lot more talk than, obviously, action. [01:15:00] What do you remember about how the potential for what the Clinton administration had planned, which obviously didn’t develop into a lot—how did that change some of your conversations or impact some of the ideas that you’d had about where the new hospital was going to go?

01-01:15:18
Kiwall:
A number of folks weren’t convinced that that model was going to work. The American public did not want restricted health care. At the time, the effort was to control costs by restricting people’s access, and it didn’t take the general public long to figure that out. People want the health care they need. They don’t want barriers put in place just for cost. If cost was going to be an issue, you need to find a better way, a more effective and efficient way of doing it. Putting barriers up to access health care was not going to be the answer. In the ‘90s, when all the managed care stuff started, you needed referrals and you needed permission to go between physicians. There was so much American backlash at that point that they were saying, “No, we’ve got a health care system that’s sophisticated; we need to be able to access it.” It was clear to many of us that that model was not going to work. It was really going against the grain of what the American public wanted. Of course, at the time, there wasn’t all the cost pressure in health care as there is today. They were saying, “Wait a minute. Somebody is trying to take advantage of this situation. It’s not going to benefit me. I’m still going to have to pay what I’ve got to pay, but you’re going to deny me access.” It was very different than today. In the last five years or so, where health care expenses have really gone up a lot—that wasn’t happening in the ‘90s. There was a different motivation. There was a different belief in the American public back then.

01-01:17:04
Rigelhaupt:
Did insurance companies, as one of the major reimbursers—Medicare, I think, is probably close to half of—

01-01:17:13
Kiwall:
About forty percent of what we have is Medicare, yes.

01-01:17:16
Rigelhaupt:
And then private insurers are probably—

01-01:17:20
Kiwall:
Medicaid is probably another seven or eight percent. Between Medicare and Medicaid, you’re pushing almost fifty percent. Then the rest is private insurers and self-pay.

01-01:17:31
Rigelhaupt:
But was this era soon after the discussion under the Clinton administration that private insurance companies began to exert some cost-control pressures on hospitals that was similar to what, say, Medicare had done with DRGs in the decade before?

01-01:17:48
Kiwall:
There was some of that, though Medicare had put the single payment system in for the DRGs. The private insurance companies were more into denying things. [01:18:00] They would deny this and not pay for that. They would say there is not medical necessity for this; you didn’t put the right documentation in for that. That’s what was going on more with the private insurers. It’s been going on since then. Where Medicare was more into what I would call the bundled payment system, which, for the inpatients, worked out pretty well overall because it was a single payment for disease track. Also what happened—it was all these advancements in health care, such as sleep medicine. There were just a number of different things that started to come up that added cost on to the system. Then the accessibility of images and of testing got to the point where patients were going between physicians. Duplicate testing was taking place because one physician wasn’t aware of testing being done by another one. They didn’t have access to the information. That all started to raise the costs for health care. Now, we’re getting into the IT age, where information can now flow. We’re putting a network together now to flow that information, to eliminate that waste and duplication, and to increase coordination of care. All those things, you’ll see that as the years go ahead. We’ll be controlling health care costs by connecting all the dots and ensuring the overall application of standards of care. That, in its own right, will help get the costs down. We’re on that journey now, and starting to put all those pieces together. To me, that will be the key to having an effective and efficient health care system. We’ve got too many things available, and the coordination isn’t there yet. Coordination is what we’re putting together now.

01-01:20:03
Rigelhaupt:
From your perspective, as a chief operating officer of a health care system, does that need for coordination present new challenges to a primary care physician?

01-01:20:18
Kiwall:
It does. The biggest challenge for primary care physicians is, how is that going to happen? How many things do I need to look at? How many buttons do I need to push to get what I need? They’ve got their own efficiencies and effectiveness to deal with. The greatest challenge now is to create the information highway that’s user-friendly, so they don’t have to go to multiple systems to get that information. And for it to be real-time, so that they can look at the overall care plan, they can see the notes from the various specialists, and they can see what tests have been ordered. [01:21:00] They can now look at the person as a whole and make a determination on the next thing they need to do, and do the things to keep you healthy. To start transforming from sick care to health care. You’re going to see more and more of that. As physicians have access to that information, they’re able to have more dialogue with the patient, have the time, and be compensated for keeping them healthy. That’s when we will have arrived. The goal is to get there, and we’re working on that now. I think you’re going to see a lot of that work in the country over the next three to five to seven years. You’re going to see it shift from just health care to population health. That’s when American public and everybody else will benefit the most.

01-01:21:53
Rigelhaupt:
Are there things, looking back, that you can see that the organization learned from being involved with primary care and some of the facilities that were opened in the mid-’80s, to the concern with primary care that, to me, sounds central to the mission, which I think is unique from a lot of non-profit community hospitals. Are there things that you’ve learned that will benefit that process of, as you describe it, connecting the dots?

01-01:22:26
Kiwall:
Just the frustration with the fragmentation. They get to see the patient, but then three other physicians have seen the patient. What have they ordered? What results did they get back? What do I need to do as the quarterback of care? I learned a lot from the primary care physicians saying, “If you had a blank sheet of paper, say what this would look like. Tell me what it would look like to make it work.” They talked about this coordination of care, the movement of information, and the standards of care, to ensure that everybody is working under the same standards of care; they talked about the ability to provide that leadership necessary in population health and overall wellness. Population health and wellness happens at the primary care level, not at the specialist level. We had a lot of dialogue about that with primary care physicians, and their interest in keeping the patient healthy, not just managing their illness. It is what they would like to spend more time doing. Of anything I’ve gotten in feedback over all the years it is, “When can we get to the point where we can have that?” We’re at the point where we’re building it now. We couldn’t have done it without their guidance and their leadership because they are the captain of all our ships when it comes to our health. That’s just the reality of it.

01-01:24:00
Rigelhaupt:
But also, the history of reimbursement, both for hospitals and for physicians, is fee-for-service, for sick care. We’ve talked about it, that, ultimately, finances are important for a chief operating officer for the hospital. How has the organization maintained its focus on primary care and health care when the reimbursement structure has not always shared that interest?

01-01:24:31
Kiwall:
That’s true. First of all, what started that interest in that reimbursement structure is Medicare and the DRGs. It is a fixed payment system. Your revenue is not dependent upon extra clicks of things you do to people. You’re getting a single payment to care for them. I think you’re going to see more and more of that showing up in the future. Many of our private insurance contracts today are single-fee-based. We’re seeing more and more of an opportunity to say, “You’re going to get paid for this disease track on this patient. You figure it out.” It’s the best place to be. Now we can do what’s most effective and efficient. We’ve seen the inpatient side go down that road. Most of our inpatient contracts and, of course, Medicare is like that today. We’re seeing some of that shift. The other part of that shift—for us, it is more capturing the community and caring for the community. If we’ve got, as we call it, the heads in the beds, we try to make sure that they’re not the same heads in the beds. In fact, we open up beds by our effectiveness and efficiency to now bring in more of a population to be cared for. Are things going to be empty? No. They’re going to be filled up with a greater population and that’s what will make it work financially for us.
[End of Interview]

Interview 2 – November 1, 2013

02-00:00:00
Rigelhaupt:
It is November 1, 2013. I’m doing a second interview with Walter Kiwall on the Mary Washington Healthcare Oral History project. And I want to pick up where you left off the last time. I’m going to ask you about Stafford Hospital. But going back even before plans were being drawn up, what do you remember about the first conversations of the possibility of a Stafford Hospital? Maybe the water-cooler-type talk.

02-00:00:42
Kiwall:
It goes back to a time in the period of Mary Washington Hospital where the growth of services and needs just continued, I believe, far beyond most predictions in the region. It was very evident that we were just going to outgrow the physical facility. Something was going to need to be done. The slope of the curve wasn’t changing, and it was easy to see where the full endpoint was going to be. We started to have these conversations when clearly there was no change. We were actually going to run out of space and ability to care for the patients.

02-00:01:27
Rigelhaupt:
Was there a possibility of adding another wing or expanding the existing facility?

02-00:01:34
Kiwall:
Those things were discussed. The facility had already been expanded a couple of different times, including a hundred-bed tower that was put on the front—that we talked about before. But really, when you looked at other options related to expanding it, there are really two big issues. One was access. With the road system and the growth of the amount of traffic, it was getting harder and harder for everyone throughout the region to get to the Mary Washington campus. And the second thing was, really, the only viable option to add on to the building was to go up. The building, when it was constructed, could go up a couple of floors. Of course, the challenges with going up a couple of floors and building on top of a hospital that has patients in it becomes a real challenge, and a challenge in which you would have to empty out sections of the building in order to handle the construction that was taking place. There was nowhere for the patients to go. But the biggest, pressing issue was access. We really did need to take services away from the campus.

02-00:02:46
Rigelhaupt:
In these initial conversations of possibilities, did you think of other locations besides Stafford?

02-00:02:55
Kiwall:
Of course. [03:00] When it was determined that we were going to need to have a second site, our strategic-planning department did a lot of research and looked at growth throughout the various points in our region. It was clear that a lot of the growth, because of the continued expansion of the Washington D.C. metropolitan area, was pushing down into the central part of Stafford. A new exchange was being put off in off of I-95. It was felt that that growth and ability to access, the most critical elements, were those up in the Stafford County area.

02-00:03:47
Rigelhaupt:
Was there public discussion before officially filing the application for the COPN with the state?

02-00:03:47
Kiwall:
We had some discussions with officials of Stafford County. I believe some key individuals in the community were involved. We had to have some of those discussions because it was going to be a significant change. It was felt that it wasn’t a sign that Mary Washington Hospital was going to be anything less. Actually, it was a sign of Mary Washington’s scope growing even more, which it has. Even since planning the Stafford Hospital, a number of new services have been added. Those kinds of conversations were taking place about a second facility. We would be able to treat patients for those regular types of conditions you would see, and permit us to continue to advance and grow Mary Washington into a tertiary-care facility.

02-00:04:47
Rigelhaupt:
So the initial idea for Stafford Hospital was to have it follow, perhaps, more in the model of what Mary Washington Hospital was, when it was in this building—more of a community hospital with a lot of this highly specialized care—would be the flagship campus?

02-00:05:04
Kiwall:
Yes, it was. The idea being that, to have some of those specialized services, you need to have feeder systems for the patients, so that you have sufficient volume to ensure that you can attract quality people and ensure quality services. Yes, those conversations took place. And as time goes on, as Stafford gets more mature, they’ll be looking for potential specialty services, even, to offer at Stafford Hospital.

02-00:05:33
Rigelhaupt:
In these initial conversations, as you were imagining this hospital being built, beginning to make some plans, did you get a sense that you and your colleagues in the administration thought that Stafford Hospital, as a kind of feeder facility, as you said, would attract different patients, different volume, than some of the primary-care facilities that Mary Washington Healthcare was involved in, even the freestanding emergency department at Lee’s Hill? [06:00]

02-00:06:04
Kiwall:
Right. Yes, of course, the big issue was access. Another reason to put the freestanding emergency department at Lee’s Hill—we had a couple of new access points we needed to have, and Stafford was one of those. With the idea that we could, obviously, put inpatient beds and inpatient services there, as well. We could effectively cover the region with a new hospital in Stafford County, and a freestanding emergency center down in the Massaponax region of Spotsylvania County.

02-00:06:37
Rigelhaupt:
These initial conversations about the possibility of a Stafford Hospital—were they coming from the administration, or the board, or a combination of the two?

02-00:06:50
Kiwall:
There was a lot of discussion in combination of the two. Obviously, leadership or administration needed to be bringing the data and the information to the board to have that discussion. Of course, clearly, it was a board decision. The board was fully engaged. Through that dialogue, that interaction, and the leadership of the board of trustees, the decision was made to build this community a brand new hospital, and, at the same time, to move forward with expanding the services of Mary Washington Hospital.

02-00:07:24
Rigelhaupt:
Is this something where you or another senior administrator will come and make a presentation to the board, or is there casual conversation about a big expansion like this before, say, a formal presentation takes place?

02-00:07:40
Kiwall:
The initial steps are some of the strategic planning work on predictions. What are the volumes? What’s the growth? We were having those kinds of discussion and looking at the capacity of the existing facilities. The initial discussions were, what can we look to do in the future? How are we going to cover the needs? What are the gaps? And then, it was evident to the board of trustees that Mary Washington Hospital’s physical facility, on its own, would not be able to cover the long-term needs of the region. Once that was determined, then the discussion started about, Okay, what is it and where?

02-00:08:19
Rigelhaupt:
Were you part of one of the early, formal presentations to the board?

02-00:08:24
Kiwall:
Yes, myself, the CEO, and CFO. All of us were heavily involved in putting the information together, preparing the options, and presenting what we thought were the viable options for the board of trustees to then make the ultimate decisions as to where they wanted to take the newest hospital in the region.

02-00:08:47
Rigelhaupt:
Did you get hard questions from the board?

02-00:08:50
Kiwall:
Sure. Going from a single community hospital to a health system with more than one hospital is a huge leap. [09:00] There’s a lot of work that has to be done. There’s a significant amount of investment. In this case, the investment could have been upwards of $155 million. When you’re talking that kind of investment, there were a lot of questions, a lot of information that had to be had, and things we had to go back and bring before the board. So yes, they were very engaged. The board asked many questions to make sure they had all the information that they needed to make the final decision.

02-00:09:32
Rigelhaupt:
Were there members of the board who were skeptical?

02-00:09:37
Kiwall:
There’s going to be tough questions. There’s going to be an understanding that this is a huge investment. When this is a huge investment, there’s going to be a lot of folks that are going to express caution. We had to work through that caution. I wouldn’t necessarily say “skeptical.” I would say to make sure they were fully informed. They had every precaution being taken to identify every single risk that’s possible’ because, at the end of the day, it is the risk that you don’t identify that could cause your organization some difficulty. With this type of investment, if, in fact, it truly did not work, it could be a substantial setback to the organization.

02-00:10:27
Rigelhaupt:
In between the time that the board decides that this is a plan worth pursuing, and the time you file the COPN application, was there input from the community about the possibility of a Stafford Hospital? From what I remember glancing at the COPN, there was community support letters.

02-00:10:50
Kiwall:
Yes. There was contact to key groups in the community. Of course, there were some hearings that took place on the COPN. We had to engage folks. We had to explain to them what we were doing and why, and see if they would be supportive of it. We had a number of physicians step forward, other folks step forward, saying, “Yes, we need to do this.” We did have those conversations, because we wanted to embrace the community. Because, at the end of the day, it’s the community’s health system that we’re providing, and we all recognize that.

02-00:11:27
Rigelhaupt:
Were you involved with any of the hearings directly, in terms of presenting? Or were other members of the senior administration involved?

02-00:11:40
Kiwall:
Yes. There were a number of members of our leadership team involved. I was involved a lot in the planning aspects, putting together a lot of the information, working with the attorneys, working with other resources in the region, and talking about the traffic congestion. All those kinds of studies were brought forward to say, “Look, we have got to do something that’s got to be off the campus.” [12:00] We engaged a lot of folks. I did get a chance to speak during their hearings, because there were a few hearings that were involved. I believe there were three. I was engaged to speak at some of those hearings on some of the work that we had done, or some of the leadership that I had done. Our CEO, Fred Rankin, and others definitely spoke about why we needed to do this for the community.

02-00:12:28
Rigelhaupt:
Were you able to make connections between the success of the new Mary Washington Hospital, its role in the community, its importance, and why this organization had a track record, at this point, of expansion and growth?

02-00:12:42
Kiwall:
Yes. The fact that we had done it—creating a 400-plus-bed campus demonstrated that we’ve got folks that can get it ready and get it open. Almost all of us that were involved in opening the new Mary Washington Hospital were involved in the Stafford Hospital project as well. But we also brought some outside resources in to help us, to provide some guidance. We worked for years in preparation to get it ready.

02-00:13:18
Rigelhaupt:
When you say “outside resources,” what do you mean?

02-00:13:21
Kiwall:
Usually folks who were involved in establishing what we call Greenfield Hospital—what are the key elements of the work plan for that? Unlike Mary Washington, which was moving a hospital, this was creating a new hospital. There are some pretty significant differences between those. Getting the physical plant ready, getting the staff ready to go in the building, accomplishing the patient move, and all those kinds of things are significant challenges in their own right. But with the brand new Greenfield Hospital, you’re not moving staff. You have to create a medical staff. You have to create a whole new set of medical staff bylaws. You’ve got to set a whole new set of operations, new staff, and staff that are not familiar with each other. Clearly, the staff is not familiar with a building that’s not even in existence yet. Some of those challenges required us to have meetings. We had meetings years ahead of time. We had a twelve-point committee. We have twelve points of key elements that individuals were responsible for, and we met, at least early on, monthly; it went to twice a month, and then went to weekly as we got inside the year. We had milestones. We had Gantt charts and work plans; and we assigned colors of green, yellow, and red, to where we are at achieving the milestones in order to get to the ultimate goal. Folks were very engaged, and each had their part. It worked out really well. We had interim medical executive committee of about eight physicians. [15:00] We met on a regular basis about what does the medical staff need to look like? What do the bylaws need to look like? What rules do we need? We did that for a couple of years before we opened it. It was quite extensive, as you can imagine; a hospital facility is complex in the first place. What was great about it is each person who had their leadership responsibilities on a twelve-point team took it very seriously and made sure that their element was tracking along according to the timeline that we had established.

02-00:15:42
Rigelhaupt:
At the time the commonwealth approved the COPN—I think Stafford was the first new hospital in the state in thirty years?

02-00:15:54
Kiwall:
Yes. A Greenfield hospital.

02-00:15:58
Rigelhaupt: And they also approved a hospital eighteen miles south—

02-00:16:05
Kiwall: Yes. Well, six miles south of Mary Washington, yes.

02-00:16:07
Rigelhaupt:
—of Mary Washington, and eighteen miles south of Stafford. Was that surprising?

02-00:16:16
Kiwall:
Somewhat. We clearly felt that we had built a case for the need to put the Stafford Hospital in place. I don’t know that anybody predicted, at the time, that both facilities would be approved. It really created an interesting scenario for the region. But it also meant that now there was three hospitals where there used to be one. Access for everybody in the community was clearly elevated. And that was okay. We still had our plans. We were going to push forward with our plans, and we did so.

02-00:16:59
Rigelhaupt:
Did that change any of the projections?

02-00:17:03
Kiwall:
No, not really for Stafford Hospital. A lot of the Stafford Hospital market was not towards where the HCA facility is in Spotsylvania. It didn’t change that much. Though what it did for Mary Washington—fully understanding when you open three hospitals, patients are going to go to three hospitals. It opened the opportunity to move along with the advancement of services at Mary Washington Hospital. Now, fully understanding that some patients would be going to three hospitals instead of two, we could go ahead and advance the services of Mary Washington a little faster than anticipated.

02-00:17:48
Rigelhaupt:
What are some of the first steps you and your colleagues took as soon as the COPN was approved and you knew you were going forward with it?

02-00:18:00
Kiwall:
The first step was to put together a twelve-point committee. We needed to get things in order. We needed to complete the purchase of all the real estate, because there were multiple purchases on the real estate that I got involved with, which took some time; it was not a single parcel of land. We got to working on key elements: everything from IT, to staffing, to supplies to general logistics, to the nursing model, to the medical staff, to the development needs of what services were going to be there, to the construction-project timeline, and all the elements associated with it. Instantly, we had the twelve-point key elements identified, and we got the COPN approved. We were ready to launch and get working on the details.

02-00:19:03
Rigelhaupt:
Because this was relatively undeveloped land from the ground up, were there any surprises with construction, or was that part relatively straightforward?

02-00:19:14
Kiwall:
There are always surprises with construction. If anybody tells you otherwise— The reason there’s always surprise with construction is until you get into the land, until you get onto the site, and until you put shovels in the ground, you’re not absolutely sure what’s there. At the end of the day, where’s there soft ground? Where’s there hard ground. Where’s there rock? How do the streams flow? Where are there hidden springs underground? All of those things, kind of, crop up. Are there special situations at the site? Do you discover something that wasn’t there, that may have significance? Is there an old fuel tank that some farmer used, buried in the ground? Do you now have to do the abatement of all the land around it because some of the old fuel leaked into the dirt? Those kinds of things all happen because, over the long history that America’s been here, many things happen on various parcels of land. You have that, and, really, the challenge of bringing natural gas to the site because there wasn’t any natural gas at the site. With hospitals, you always want to have two electrical sources so that if one substation, one major grid, goes down, you have another one going. Where is that going to come from? How is that going to be connected? And then, we have the whole challenge of IT connectivity, fiber-optic connectivity, to move data. We have to get a line in and an alternate line in in case somebody mistakenly puts a shovel in the ground and decides to dig something for some reason without calling somebody. Now, all of a sudden, you don’t have a data connection. [21:00] Figuring out the pathways for all of that and getting across the river—we had to get across the river with the data connection. It was all those kinds of challenges. The right of ways on the highways; the turn lanes are part of the proffers that have to be put in place to make sure the traffic moves safely. Who owns that? Or there’s a decision that it needs to be a little wider; now you’ve got to buy that little piece of land. All those kinds of things when you’re dealing with a piece of property that’s over seventy acres and owned by a number of individuals.

02-00:21:39
Rigelhaupt:
When those smaller issues popped up, like buying a smaller piece of land and dealing with those purchases, was the community largely supportive, or did it present any challenges?

02-00:21:50
Kiwall:
Very much so. The only challenge is usually when you’re purchasing raw land, many times there’s more than one person that owns it. A lot of raw land is passed down through generations. Maybe one person owned it many, many years ago, but because of estates and things, they get moved along. You usually end up with multiple owners. You have the challenge of working out the details with multiple owners on the purchase. The purchase, the use, and the easements—all those kinds of things get to be greater challenges the more and more people that are involved.

02-00:22:29
Rigelhaupt:
Were you mostly working with Stafford County officials in terms of easements, roadways?

02-00:22:36
Kiwall:
Yes. A lot of it was working with the Stafford County officials. They did a great job of helping us navigate all the areas we needed to deal with. You’ve got zoning changes. You’ve got proffers. You’ve got permits. You get all those kinds of things. Frankly, they did a great job at assisting us so that we could move it along and create a brand new hospital a quarter mile from the courthouse. That turned out really well.

02-00:23:07
Rigelhaupt:
Did you end finding any surprises in the ground as you were digging?

02-00:23:11
Kiwall:
As you could imagine, you’re going to find some graves. When you have large tracks of land and various people lived on them over time—families buried family on family property for many, many years. You have to treat those situations with a lot of respect and do whatever’s right to do related to getting the remains moved to the appropriate site, such as contacting family if you can find family. In some cases, you can’t, because there’s so many generations removed. When you do find those situations, you’re going to treat it with respect and you’re going to make sure that those things are all handled. That was one of the things. We did find the old tank site that some farmer had diesel fuel in, or whatever; we had to deal with some of that. [24:00] And then, just some of the civil engineering—what I mean by “civil engineering” is how, in fact, do the footers need to be done, based upon the soil itself, and the rock? That can differ from short distances. There’s a lot of civil engineering involved and a lot of core sampling involved. You end up needing to put extra here, or a little different methodology there. Those are decisions you have to make, pretty much, as you discover them. It really wasn’t anything insurmountable, because the community as a whole—and even the people who owned the property—was supportive of a hospital being built in Stafford County. It worked out well.

02-00:24:47
Rigelhaupt:
It sounds as though, because it was brand new and not moving patients, some of the construction was newer. What are some of the things, though, you learned from opening the new Mary Washington Hospital that you directly applied to patient rooms, building out not the building—because it could have been almost anything—but that made it a hospital?

02-00:25:17
Kiwall:
There are a few things. One of the things I thought was very helpful—we decided to do mockup rooms in some of the shell space in Mary Washington Hospital. We actually physically built the rooms, a patient room, a critical-care room, and a labor-and-delivery room. Then we had nursing personnel test the rooms out. Was this dispenser in the right place? Or, when you went to do this, did you bump that? All those things that you can’t look at a drawing and do. I think one of the successes of the utility of the patient rooms at Stafford was the fact that we were able to test-drive them with clinical staff. We had a lot of discussion about that. We had built on a number of times at Mary Washington, and it’s always the same: “Boy, if I had just had a chance to try this. If I would have had a chance overall to see how this is going to flow, I could have made some suggestions on things.” When we moved in Mary Washington we heard some of that. So we said, “Okay, we’ve got some shell space in the building. Let’s build the rooms. Let’s outfit them, and let the staff walk in and act like they’re treating a patient. Let them see what works and what doesn’t work.” And we moved this and changed that. We did a lot of things associated with the feedback of the staff.
That was a moment of big learning. The fact that we got to spend a good bit of time with the staff kicking the tires—in other words, going over, walking around, and finding out where things are before you start to need to use them. One of the big things about a facility, since you don’t get to do this very often—open a brand new facility—is the understanding of how important it is for the staff to feel comfortable in the space. [27:00] I think one of the bigger challenges of moving versus opening a new Stafford Hospital was people who had facility knowledge and were sources of information no longer existed. Nobody had worked up in the new hospital before. You couldn’t ask somebody where this was. You couldn’t say, “How’s the quickest way for me to get from here to there?” It was a challenge, and associates that spent a lot of time working here—it took that away from them. They had spent a lot of time here and it was their place. They knew it. People can come to them. We quickly discovered that that’s an important element; we took some of those folks and had them start to be the initial experts with the new facility up on the hill. That, in its own right, said, “Look, we’ve got to work our staff through. We’ve got to take them through orientation. We’ve got to do all those kinds of things.”

02-00:28:15
Rigelhaupt:
What percentage of the Stafford Hospital staff came from Mary Washington Hospital as it first opened?

02-00:28:22
Kiwall:
I believe it was about ten percent. One of the things that wouldn’t help us is to take staff needed at Mary Washington and move them up to Stafford. As they say, “Robbing Peter to pay Paul.” It just didn’t make any sense. We took enough up there who know the systems that might be the same. In the case of the nursing systems and mothers—there are folks who had system knowledge. We took enough of them up there. But we did not want to take people who were well familiar with and well trained in their sub-specialty areas and move them up the road. It just didn’t make sense to do that. We basically went out and hired, for the most part, a new staff.

02-00:29:08
Rigelhaupt:
What did it mean for the organization to add that much new staff in a short period of time and in a concentrated way?

02-00:29:18
Kiwall:
It was a lot. We put on full time and part time, probably 500 people up there. Putting 500 people in the organization almost at once is a huge challenge. How do you get them in? How do you get them screened and cleared? How do you get them oriented? We had to put additional resources on for all aspects of that, so that it could take place. Then we had to bring more resources on that were just Stafford resources before we opened the facility. People spent time doing that, since the facility wasn’t open. The nurse managers and others started to be an extension of the human resource office; because, let’s face it; they didn’t have anything to manage yet. [30:00] Their job was to make sure that they’re getting the staff in, getting supplies in, getting policies in, getting procedures in, and getting all those kinds of things in. The good news is we were able to use them for that, since they didn’t have an operation to run at the time.

02-00:30:27
Rigelhaupt:
Could you describe the opening?

02-00:30:30
Kiwall:
It was one of the most joyous things, I think, in my career. You work so long on something of such a magnitude with so many good people. The day that I stepped on that ambulance to announce that Stafford Hospital Center was open for patients was one of the best times in my career. To look around and see all the people who were involved in the ribbon cutting and almost hundreds of folks that said, “We’re going to make this work.” To think that we were able to do that, at the same time saying, “We’re open. Goodness sakes, it needs to all work. It needs to all work.” And it did. It showed that there were a lot of folks that did a lot of good work to open one of the most complex businesses that one could ever open. They made it work, and cared for the patients to the highest quality that a community hospital could do. It was a tribute to a lot of good folks. I was proud of the team. They did a super job, every single person that was involved.

02-00:31:48
Rigelhaupt:
What do you remember about the first patient that came in?

02-00:31:52
Kiwall:
They came into the emergency department. As you can imagine, as you’re getting ready to open a hospital, things are happening out in the community. Since there is no elective work to start with, it’s the emergent work that’s going to be the first ones. And frankly, as we’re saying it’s open, the ambulance is pulling in the emergency department. Of course, the first patient was an emergency-department patient. Quickly thereafter, ambulances started coming in. The first day is pretty much handling emergency-room patients. You want to make sure that everything’s working, and then you’re opening it a little more at a time. “Okay, let’s bring some elective work in, some lower level elective work. Is all that working? Well, that’s all working. Okay, we can bring a little more complex work in.” We systematically ramped up the acuity to make sure that everything was working and that patients were cared for in the right way. We took our time, put in extra resources, and made sure it worked. Job one was taking care of the patients. If that meant we put more resources than we would normally put at it, then fine; but from day one on, it needed to work. [33:00] Once everybody got more familiar, we could start to adjust resources. That’s exactly what we did.

02-00:33:13
Rigelhaupt:
Speaking of the emergency department—that is the point of entry for the first patients is Stafford Hospital. Do you remember distinct things in terms of that program and that service that was brought to Stafford Hospital because of the experience that you and your colleagues had developed in building Lee’s Hill? And, at this point, there was now a trauma program at Mary Washington Hospital.

02-00:33:39
Kiwall:
That’s correct. That was, in my mind, one of those areas of opening a hospital up that we had more comfort in because we were using the same physician group. The Fredericksburg Emergency Medical Alliance has clearly been a quality emergency-room group. They had the experience of opening Lee’s Hill. They had experience of running a very busy emergency department that became a trauma service. We knew that the physicians had the capability of handling whatever is going to come in that door up there. And that’s good to know, because that’s the first ones to get the patients. Let’s face it; many of those patients are the sickest patients that are going to enter the building. You want quality resources there. We were fortunate that the existing emergency room group worked with us, and was interested in covering Stafford Hospital, as well. That gave us a lot of comfort, and it proved to be a very good service.

02-00:34:45
Rigelhaupt:
And in terms of a service like trauma that involves more than physicians, were there nurses that had higher-level skills that also come up from Mary Washington Hospital, to work in the emergency department?

02-00:34:59
Kiwall:
There were, because we had them. As you know, Mary Washington is large enough where there are a lot of sub-specialty skills involved. We were able to tap some of those protocols, pathways, and techniques, based on particular patient populations that our nursing staff and our physician staff had put together. Stafford didn’t have to start that with a new playbook. We had a playbook they could use for those patients. That care was coordinated. There was coordination between the emergency departments and an overall synchronization between the emergency departments. That really made it good. It gave us a lot more confidence that we were going to be able to open this up day one and it was going to work.

02-00:35:55
Rigelhaupt:
What do you remember about the first baby to be born at Stafford Hospital?

02-00:36:00
Kiwall:
That’s the other critical element as you look at a hospital service. Bringing someone into this world is a significant event. It’s one of the most personal events that a family could have. And, as they say, the trip of birth is one of the most challenging trips anybody will ever take in their life. We needed to have the right kind of resources there. We made every effort to make sure we had experienced folks and knowledgeable folks, so that mom and baby could be cared for, and it was a non-event. As a matter of fact, the first full year of operation, we had some of the highest quality numbers in our labor-and-delivery area—as good as anywhere in the other parts of the organization. It worked out really well.

02-00:36:59
Rigelhaupt:
Part of the marker of Stafford Hospital is Mary Washington Healthcare becoming, really, a multi-unit health care system. As you were developing Stafford Hospital in terms of IT, for example, were there things that you were putting in and implementing for Stafford, and as you were doing that learning, that you brought to Mary Washington Hospital as well?

02-00:37:26
Kiwall:
Absolutely. One of the more recent events of that was CPOE—Clinical Provider Order Entry. The physicians and the extenders are using a computer system to put orders in. We test-drove that up at Stafford because it was a smaller venue to test those things out. That will happen in the future, as well. We’ve tested a number of things up there, because it’s a lot more controlled environment. The health system will continue to do that. We were very fortunate be able to get CPOE in at Stafford and extend it to Mary Washington. Now it’s in both facilities. Yes, I think you’ll see more and more of that as time goes on.

02-00:38:18
Rigelhaupt:
As we talked about the last time, you also talked about Mary Washington Hospital staying contemporary, and continuously being reinvented. Are there other things that you would see as either connected to Stafford Hospital, or were going on about this time period, that kept Mary Washington Hospital contemporary?

02-00:38:40
Kiwall:
It continued to grow and advance the upper-level services: things like our heart program, our neurosurgical program, our thoracic-surgery program, colorectal-surgery program, and cancer program, as a whole. Those were all things, because of size and volume that you could now bring to this community. [39:00] To have a resource such as the tertiary-care facility of Mary Washington Hospital in a city the size of Fredericksburg is not typical throughout the country. Our job, we felt, was to bring the highest level of care to this community; higher level than you could expect to see in communities like it. I believe, through the leadership of our physicians, our board, and our leadership team, that’s been accomplished. That’s not an end journey. This journey’s going to continue on and going to keep looking for ways to advance and bring the most advanced services to people in this region. That’s the beauty of a health system, of having enough size and sophistication and complexity to do that. The other benefit of Mary Washington becoming a health system for the community is now there are services available that would not normally be available if Mary Washington was the only community hospital around.

02-00:40:21
Rigelhaupt:
One of the things I’ve heard from a board member is, we were talking about the mission, the real commitment. But also he said, as a kind of shorthand, “If there’s no margin, there’s no mission.” And I’m wondering if the expansion changed some of those decisions? That some of the services or programs—they’re not all equally generating revenue. Was there a change that you, as chief operating officer, in particular, noticed that you were going to have to take into account as there are multiple facilities, and that it changed some of the ways in which you had to do your job?

02-00:41:09
Kiwall:
Absolutely. With size comes complexity. With complexity, there becomes the need for advanced systems. We have got over 4,000 people that work in our organization. That’s different than, I think there were 1,700 when I arrived here. We have almost thirty sites, I think, at this point. The idea of the coordination, the efficiency, and effectiveness—of the use of resources—becomes absolutely paramount. You’ve got to be able to do that in order to control the cost and ensure the quality. The foundation of quality is standardization. Doing it the best way and doing it that way all the time. [42:00] It challenged our operations folks to say, “Look, we’ve got to constantly look for better ways to do things, so that we can effectively use scarce resources and get the quality outcomes we want.” We started an affordable care committee and said, “Okay, what kind of things can we do?” We put business managers in place in the operational centers of excellence because we needed to find where we have opportunities to get more effective and efficient. We’ve been on that journey for years now. Probably it’s just around the time, right after Stafford Hospital opened, we got those groups together and started working on this, with the idea of knowing we have got to get efficient. We’ve got to get effective. And, at the same time, we have to make sure that the quality is going in the same direction.

02-00:42:55
Rigelhaupt:
It is fair, then, to say that Stafford represented more than just a new hospital? It represented, or forced, or created the opportunity to make some of these changes within the organization?

02-00:43:09
Kiwall:
It did. It required us to look at things differently. Because when you go to multiple sites for large services at whatever business you’re in, it forces you to step back and think about coordination and effectiveness and efficiency in a way you never looked at it before. It’s a lot easier, in a single building, to look at and manage resources. But as we got greater in size, sophistication, and location, now it demanded that we become a lot more sophisticated in use of resources, management of resources, and movement of resources. Those things became the order of the day.

02-00:44:01
Rigelhaupt:
When Stafford opened, if I’m correct, you continued to serve as chief operating officer, and you were also president of Stafford Hospital.

02-00:44:08
Kiwall:
That’s correct.

02-00:44:10
Rigelhaupt:
What was exciting about having both of those roles?

02-00:44:13
Kiwall:
I think it was a part of the board recognition for the work and leadership to get the Stafford Hospital opened. Clearly, we have a site administrator up there, like we had a site administrator at Mary Washington, as well. I spend a lot of my time since Stafford opened on business development, both in services and access. It was great that the board took an opportunity to go ahead and designate me as president of Stafford Hospital when we got it open. It was very appreciated at the time, and still is.

02-00:44:56
Rigelhaupt:
I want to go back roughly twenty-two years—and I know that’s a jump in time. [45:00] How would you describe the core values of Mary Washington Healthcare and MediCorp when you started?

02-00:45:11
Kiwall:
One of the reasons I came here—there were a couple of primary reasons. One was the values. It was clear to me, when I was being interviewed and I had my own opportunity to ask questions about it—what does this organization want to do? How does it see itself moving forward? What’s important to it? I wanted, frankly, to see if serving the community was job one. That’s what I was looking for, and that’s what I heard. What I heard loud and clear from the people during the interview process is that the community counts on us. We are medical care for this community, and we have an obligation to meet those needs. That was a big thing for me. And the values of we’re always going to be open and honest. You’re asked a question; you’re going to give a straight answer. There was never anybody that tried to skirt any answers, or provide information in a way that would leave facts out, or create an illusion of any kind of situation. You were always clear where everybody stood. At the end of the day, if a tough decision had to be made, the directive was you make it based on the mission. If you’re not sure, the final straw is, does it meet our mission? To me that means a lot. When the mission was, at that time, to improve the health status of the people in the community. Those are all very, very important things to me. It’s why I’m in this business.

02-00:46:54
Rigelhaupt:
Twenty-two years later, would you say that the values are the same?

02-00:47:00
Kiwall:
I do. I still see this health system doing a lot of things because the community needs it, not because we make money on it. As a matter of fact, there are a number of things we lose money on that we do. And that’s okay, because those things are needed. We need to use all of our expertise and our skills to make sure that those other services that we offer— that we can have margins on—that we are doing that the best we can. Even on the ones that we’re losing money on, it’s not just losing; it’s how much are you losing? What can you do to minimize those losses and still provide quality services? Those things are important. Those things exist today. We’ve got a number of services the community needs—there’s been a demonstrated need—and not all those have margins to them. That’s what separates us from the for-profit businesses. [48:00] We’ve got that mission and we’ve got that obligation to the community. That stands today as it did back then.

02-00:48:11
Rigelhaupt:
Over the last twenty-two years, there certainly has been significant change in terms of how hospitals are reimbursed, their relationship to state and federal governments—all the things that affect the operations of the hospital. So how does an organization maintain, say, a commitment to the community and those core values?

02-00:48:38
Kiwall:
We’ve got to always look at better ways of doing things. I don’t mean just making something a little bit better. I’m talking about transformational change. That’s what going on today: the development of coordinated care through networks. Working networks with the independent medical staff is where health care is going. The movement of patient information, the coordination of care—technology permits us to move patient information today. It did not permit us to do that twenty years ago. It just couldn’t move it between facilities or different businesses. That capability exists today. So you’re going to see the health care providers, both physicians and health systems, redefining the health care model. It’s going to be one where all the patient information is connected and the care of the patients is connected. The patients that have significant health challenges are not only managed at the point of care, but they’re going to be managed and helped between the points of care. It’s in a process of changing, and you’re going to see that soon.

02-00:49:56
Rigelhaupt:
One of the things that started almost simultaneously, but I think about a year or two after you began here, was the Community Service Fund. What are your memories about how that started and what it meant for the organization?

02-00:50:13
Kiwall:
There were a lot of discussions. I believe it was between Fred Rankin, our CEO, and Joe Wilson, who I believe was the hospital chairman of the board at the time. We were not only a hospital in the community, but one of the largest businesses in the community. What could the hospital and health system do to work with other community entities to help improve the health of people in the community? How could a fund be set up to do that? I believe the two of them worked with our foundation and the board of trustees, and they came up with the Community Services Fund. That Community Services Fund, as you know, gives grants. Those grants are to assist with health and health-related issues. [51:00] I think you’re going to see more of that. You’re going to see more focus, as time goes on, and more coordination as time goes on. It’s a great tribute to the board here and the commitment to the community; that goes beyond what would be the normal hospital commitment to the community. It is another great reason to be here, and one of the great reasons that I’ve stayed here all this time. It’s that kind of thought and commitment that make a difference.

02-00:51:44
Rigelhaupt:
So in terms of the grants with the Community Service and the Community Benefit Fund, as you’re well aware, in terms of your job, non-profit community hospitals have a long history of providing charity care, or making sure that even people who cannot pay, ultimately, are provided medical care. Why was the decision made to invest in these grants and the Community Service Fund, versus reinvesting those funds in the organization that really did participate in charity care?

02-00:52:30
Kiwall:
I think it was looked at as a way to engage other not-for-profits in the community to help with improving the health status of the community. As you know, a number of organizations in the community receive those grants. The free clinics receive those grants. Others who receive grants clearly have the line of sight on helping to improve the status or identifying medical issues through screening processes; it includes churches and other things. The grants are going to make the health of the community better. We were fortunate to have those kinds of organizations in the Fredericksburg area. It was felt that those resources could be used to improve the health status, by using their staff, their resources, their knowledge, and with some of the Community Benefit Fund funding, to accomplish those things and to partner with those facilities to accomplish those things. I believe, at least my view of it was, why create your own infrastructure to do some of that when the infrastructure already exists, and a number of people were already engaged?

02-00:53:39
Rigelhaupt:
Can you think of instances where, in your job as chief operating officer, you were involved in this? Or even at the level of bringing some of your expertise in terms operations or programs, did you work with some of these community programs to improve that infrastructure?

02-00:53:56
Kiwall:
Yes. We have spoken with, helped, and given them some ideas because health is our space. [54:00] Also, we’ve served on boards. I serve on Guadalupe Free Clinic Board. I still do today. In a small organization like that the board becomes the principal resource, versus just a governing resource. We’ve had a lot of discussions about the efficiency and effectiveness of the clinic, the access to personnel, and the needed personnel to do things. Yes, in one venue or another, many from the leadership team sit on the boards of many of these organizations. They’re able to, then, provide some of their expertise for operations. Many of the organizations are very small, at the end of the day. They really don’t have large pools of resources to pull from.

02-00:54:53
Rigelhaupt:
Another aspect of the Community Service Fund, now the Community Benefit Fund, that I see as unique, is that it has a concern with public health, which has not traditionally been a central concern with acute-care hospitals. In your role as chief operating officer, how do you think either some of the programs that you know the Community Benefit Fund contributes to, or your day-to-day job at Mary Washington Healthcare, is connected to these concerns about public health?

02-00:55:36
Kiwall:
The public health becomes the health system’s concerns. Identifying high blood pressure in people and identifying diabetes early on could get them in the right setting, versus them not having that access, crashing, and coming in through the emergency department. It means affecting their personal health in a way that could have been avoided and driving the cost of health care up; they’ve come in and used advanced resources. When, if things could have been identified earlier, that could have been avoided. As a chief operating officer, for me, we want the patients to enter the acute-care system that should be in the acute-care system. If there’s a way to keep them healthier and in a different setting. If there’s a way to keep the patient better, healthier, and to keep the cost down—then why not? Because then we get to use resources for what we’ve always intended to use them for.

02-00:56:44
Rigelhaupt:
So this is a long question, but bear with me. What I’ve seen in these interviews, and heard, is that Mary Washington Healthcare is a community center. I’ve heard it talked about in terms of the organization’s culture and the day-to-day operations. [57:00] And yet, since the 1970s and, increasingly so since the 1990s, Mary Washington Healthcare and all not-for-profit community hospitals have interacted in new ways with incredibly powerful external forces. I’m thinking about financial markets and bonds, about the Centers for Medicare & Medicaid Services, third-party payers and insurance companies, and the cost of technology. How does Mary Washington Healthcare stay focused on the community when, as an organization, it has to interact with very powerful external forces?

02-00:57:44
Kiwall:
The focus has to be on the coordination of care and health. What you’re seeing today is this coordination of care is taking off. The ultimate goal is population health. We get that. We understand that. The old fee-for-service system is not built on that. A lot of the systems aren’t built on that. It’s up to the health care providers in this country to redefine the system. Everybody’s working on that now. The adage of, the only way to control costs is just to keep cutting what you pay people to do and what they do. Well, that is not going to be a viable long-term solution, or people are going to start leaving the field. We have got to come up with a new model, and all of us are working on it now. That new health care model that we can take to the insurance companies and Medicare, and say, “Look, this is how we think this could be done better, keep the patients healthier, deal with their overall health, and keep the cost down.” There is a way of doing that. But the old fee-for-service system, of just keep cutting back what you pay people—as new technologies come in, as new advances in medicine come in, there’s a cost to those. If you keep tacking that on, it’s just not going to work, and we get that. That’s how we’re doing it. Mary Washington is positioned to leap ahead with that in the very near future.

02-00:59:31
Rigelhaupt:
For at least two decades now, Mary Washington Healthcare has had a rather close relationship with the Moss Free Clinic. Are there things that you’ve learned as chief operating officer, in terms of working with the Moss Free Clinic, that you think are shaping how you are thinking about this coordination of care?

02-00:59:57
Kiwall:
Yes. First, the free clinics are safety-net providers. [01:00:00] They are essential. They are essential because everybody needs access. We also understand there’s a lot of volunteerism for providers in the free clinics. Anything we can do to help facilitate that volunteerism—some of leaders are on the Moss Free Clinic Board. We can assist in operations and the campaigns we do to raise money for them. As a matter of fact, we have an oyster roast coming up tomorrow for the Moss Free Clinic; that’s done every year. The building they are in: we ran the foundation campaign and built it. I think we lease it to them for a dollar a year, or whatever it is. We understand the importance of that. We’re very connected to them. We anticipate staying connected to them. We’re working on coordination of the not-for-profit clinics and the free clinics in the area, so that everybody can have access in one way or another. We’ve got teams working on that now. We do see a future in that. There’s going to be a continued future of working with free clinics.

02-01:01:14
Rigelhaupt:
In terms of your background of understanding buildings, having been intimately involved in building two hospitals, did you see a benefit to having the Moss Free Clinic on the Mary Washington Hospital campus?

02-01:01:32
Kiwall:
Absolutely. There was a lot of discussion about where to put the Free Clinic. Mary Washington’s medical campus is a destination. When people think about health care in this area, that’s where they look to go. Whether you have insurance, you don’t have insurance or whatever your income is, it is the place you look to go. We felt it was more than appropriate to assign the land, to build the building, and to provide the building and services for the free clinic because it makes sense. An alternative might mean going to some distant place and then showing up at the emergency department for things that could be taken care of elsewhere. We believe it was an overall good move. There was a lot of thought process put into that.

02-01:02:25
Rigelhaupt:
In terms of things like IT and other day-to-day operations, are there things that Mary Washington Healthcare has provided to the Moss Free Clinic?

02-01:02:37
Kiwall:
Yes. I’m not aware of all the connectivity with the IT systems, although we’re in the process now of connecting the IT systems. They will be connected to the same medical-information network as all the other providers in the region. They will have that access, once we get that in place.

02-01:02:25
Rigelhaupt:
Were there other lower-tech operational efficiencies or ideas that you or your colleagues brought to the Moss Free Clinic over the years? [01:03:00]

02-01:03:07
Kiwall:
Yes. Basically, a lot of what’s brought to the Moss Free Clinic is brought by our leaders who are on its board. They can bring to bear some of our resources to help them, to get studies done for them, to say where the patients are coming from, what patients need, and what the populations need for service. We’ve done that all along with the free clinic, and I’m sure that will continue. The main immediate source for them, basically, is the folks that are on their board and have leadership roles here. We usually have a couple of them on that board.

02-01:03:58
Rigelhaupt:
Thinking a little bit about hospital administration—and this is kind of a broad question—but one of the things that’s evident about hospital administration is that people have a range of different backgrounds, from masters of public health to master of health administration, MBAs, RNs, MDs. How does the different education lead to different approaches to solving problems?

02-01:04:27
Kiwall:
I think every one of us is wired individually. There are strengths and attributes that pull us in a particular direction and that we warm up to certain opportunities and professionalism. There’s no one single science that makes it all work, whether it’s administrative science, engineering science, nursing science, physician or medical science, process, or industrial engineering. We’ve got folks with all kinds of varied backgrounds. The thing about us is there’s a lot of process involved. Rarely, is there a service that a single individual does with a client, like a stockbroker does with their client or an accountant might do with their client. In most of our cases, there are numerous people involved in providing a service, which means we need a lot of different kinds of talent to ensure that that service is provided in the right way. It’s one thing to have the core knowledge to provide your element of this service. But how do we make sure the patient or the customer ends up getting that service in a coordinated way from multiple touch points? That’s what makes the whole blending of the sciences absolutely necessary. That is why we’ve got people with engineering backgrounds and we’ve got people with, like you said, public health, health administration, nursing, pharmacy, physical therapy—all advanced degrees with lots of training involved. [1:06:00] The level of accountants we have here, the level of finance people, the level of materials management, logistics, is very complex. We spend over a $100 million a year just on medical devices. How do you move that stuff? And how does it get stocked? And how is it supported? It’s massive. It’s a massive undertaking. Therefore, we need people with varying backgrounds. It’s what makes it work. If you had a single background, it would never work. You just can’t find the breadth and depth of skill sets in any given profession. It needs to be a blend.

02-01:06:54
Rigelhaupt:
Can you think of an instance where, perhaps you as an MBA for example—could you describe where some of your training, you approached a particular problem solving problem, maybe around something with opening Stafford Hospital. I’m not thinking of anything in particular, but the way you would approach a problem and trying to solve it was different than a physician, for example, or someone else? And how you worked through that?

02-01:07:24
Kiwall:
Some of my background—I have an associate’s degree in engineering, an MBA, as well as an undergraduate business degree. It’s a lot of the things, as far as my formal education goes and the tools and techniques I utilize for what I would call long-term projects. There were a number of sciences where it’s, “Here, now solve it, and move on to the next.” My ability to put long-term projects together—the Stafford project, I believe the Gantt chart had 17,000 lines to it. The ability to do this, then that, then this, then that, and then decide what the success indicators are for those—the ability to create those models were all things that my professional training brought. Even though I couldn’t perform an appendectomy or provide any nursing skills to a patient, the idea of project management was a skill set that I’ve used a lot in my career. And, frankly, it came into the greatest challenge with the Stafford Hospital project—a multi-year, $155 million project that had many facets to it. Having the tools and techniques and education to put that work plan together were necessary for it to be accomplished. But there were so many aspects to that I didn’t have the skill sets in. I’m not an IT expert. [1:09:00] I’m not a finance and accounting expert. I’m not a medical-staff expert. I mean, those were all things that we had to bring to bear resources and the work team to do those. So, yes, I think you can take each one of those professions, and they could show you and demonstrate to you how they had a major portion of solving a complex challenge, to the point where it was successful. Complex organizations require individuals with many types of toolsets, techniques, and training. It makes it work. The Stafford Hospital project itself was probably the demonstration that used most of my education and training, out of anything I’ve done here. The size and complexity of it, without that formal education and that knowledge, I would have never been able to accomplish it, clearly.

02-01:10:02
Rigelhaupt:
Were there any times that there were disagreements about how to solve a problem, based on someone from a medical perspective said we should do X, and someone from finance said, “Well, if we consider Y, then—.” I guess the question is, is it a productive tension?

02-01:10:25
Kiwall:
There’s always a productive tension. Depending on what people’s professions and backgrounds are, it’s how they approach and solve a challenge that’s in front of them; it is the ability to do things concurrently versus programmatically. Can we run three parallel tracks at the same time, versus do this, then this, then this, then this? It helps to get the effectiveness and efficiency, and you’ve got to run things concurrently. As we were developing the road on the campus at Stafford, we were finishing the building. The building got done ahead of time, and we had to go to Stafford County leadership to get the hospital opened, even though the connecting road, Courthouse Road, wasn’t done. Understanding that things don’t always progress at the same way—if you would do things just one step at a time, the timeline could get unmanageable and not be feasible. The ability to bring different players with different professions, having them working on different tracks at the same time. Then, where do they merge? Who’s going to get there first? Why is this one not ready to be there now? I mean, that’s the kind of discussions that take place when you have complex projects. But it’s a good, healthy tension. And it’s about tracking mechanisms—the green, yellow, red. [01:12:00] If these three are green and this is yellow, “Okay, what’s going on? All four of these need to get to this point at the same time.” Those are kinds of good, healthy-tension discussion. Then to shift resources to help somebody if they’re getting behind because this person got sick and that happened. “Okay, what can we do?” It’s a good, healthy tension.

02-01:12:25
Rigelhaupt:
Have you worked in other environments where senior leadership has such different backgrounds? Or is this unique to health care?

02-01:12:40
Kiwall:
I worked in heavy industry before going into health care and there was definitely more similarity of backgrounds. The diversity of backgrounds is probably greater in health care. I think this organization has over 500 different jobs. And I don’t think that’s typical in many industries, because we have to do all what I would call the “typical business” stuff—the operations stuff, the maintenance of the building. At the same time, we’ve got to do neurosurgery and thoracic surgery. It becomes very, very diverse. I’m not aware of any industry that’s that diverse in professional backgrounds as health care is today.

02-01:13:31
Rigelhaupt:
Just to shift gears a little bit, in terms of thinking about how you communicate to the community. And part of that is public relations and marketing. Have you seen a change with that aspect of how hospitals communicate to the community over the course of your career?

02-01:13:53
Kiwall:
Absolutely. I think the sophistication of the communication of the services provided today is much greater than it’s been in the past, because services are a lot more complex today. The marketing ends up being mainly education to the community about the things that are available in its heath system. What’s a little unique about health care is a lot more of it is education versus marketing. “This is done here,” or “that’s done there.” These are the clinical achievements. This is the quality that’s associated with it. A lot of it is keeping the community informed about what their health system has and ready to serve them with. It’s quite different today than it’s been in the past.

02-01:14:46
Rigelhaupt:
In 1990, I think, US News and World Report launches its first “America’s Best Hospitals.” [01:15:00] How do you think that shapes not-for-profit community hospitals and some of the decisions they make?

02-01:15:11
Kiwall:
I think more of the decisions are made based upon quality established from key resources such as the Centers for Medicare & Medicaid Services. There are a number of quality initiatives that are tracked, targets and expectations that are set, and more and more attention is placed with that. Things like readmission. When you get into some of the other non-clinically driven designations of quality, I think you start to get into how they define it. I think it is so complex. I believe that a lot of the work being done by the central sources has been a lot better at identifying those key quality things. Some of the challenge today is, you’ve got a lot of organizations declaring quality dashboards or the best hospitals; and you’re the best in one and you’re not the best in the other. You can go around and around with that because there are so many services. A lot of it depends on how they define quality, and how much effort they put into getting the information. It’s going to get more and more complex. I think you’re going to see the best sources will be the ones with a lot of the providers, the Centers for Medicare & Medicaid Services. A lot of the health insurance providers are working with hospitals that come up with more and more quality indicators. I think that will be a better source for the public.

02-01:16:44
Rigelhaupt:
With these quality rankings that may or may not be all that specific to what’s going on in the hospital, did that have an effect on your job day to day as chief operating officer?

02-01:17:00
Kiwall:
It does. More and more quality matrices are put out there. Attention needs to be put to them. As everything else, we got to put attention to all the care, not just the ones that somebody’s publishing somewhere. At the end of the day, we’re going to make the decisions that affect the quality of care the greatest. It may not be tracked by some outside source, but we know that, for us to have quality care, those things are important to be in place. We will continue to focus on those things because job one is to focus on the things that matter the most. That’s what we’re going to keep focusing on in health care. You’re going to see more and more reports on those things. It’s going to get more and more sophisticated over time.

02-01:17:55
Rigelhaupt:
In our last interview, you talked about beginning to produce a network of information. [01:18:00] And you mentioned it again this afternoon. Are there models that you’re using to think about the kind of networks of information, particularly medicine? For example, Kaiser Permanente’s model—a real focus on evidence-based medicine. Where are you getting some of the ideas for what you’re building?

02-01:18:19
Kiwall:
A lot of that is coming from varying sources. The guidance put out by CMS and the accountable-care organizations, standards of care, evidence-based medicine standards of care, and the designated medical homes for patients—all those are resources as this coordination of care is being built. A lot of those things are being used as resources to put this together. Because as I said today, the one major difference is, we can move information today, in real time. When you show up at your doctor’s office, he can pull up the medicine you were ordered yesterday or some physician’s offices you were in yesterday. He’ll be able to pull it up in his office, so that he’s got all the information to treat you the best. That’s the difference today from what it was twenty years ago. We now can have and move that information. That’s going to help spark the coordination of care in a way it could never be done before.

02-01:19:33
Rigelhaupt:
What kind of opportunities does the increase in information provide, particularly, chief operating officers?

02-01:19:40
Kiwall:
The opportunities are the two big things in operations. Number one is elimination of waste; not doing it again when it’s already been done. Having access to information, you won’t have to do it again. The second is, the timeliness of the care plan, because information moves quickly. We’ll be able to move the patient quicker through their care plan. You’re not waiting for the next thing. That the next thing can be done to and for you now, so that you can get better faster and you can get home. That’s in your best interest. That’s in the costs and best interest of health care. Those two things are very much aligned. In operations—that way I can get the sick patient in the bed to their home. Then get the next person cared for so that we’re not bringing to bear too many resources and that’s going to drive up health care costs. That the efficiency and effectiveness is going to care for you better. We’ll be able to get you through the system in a more timely way and be prepared to take care of the next patient. We will not need to add another staff member or add another bed just because we couldn’t get your care plan done. For an operations person, that’s the ultimate goal. Everybody wins when that happens. [01:21:00]

02-01:21:06
Rigelhaupt:
Thinking about this coordination and everybody winning, we also said that wellness happens at the primary-care level, not the specialist level. And I’m curious if you can reflect on what this means for hospitals, which have traditionally been centers for advanced, acute care, and the ways in which you’re thinking about and the industry’s beginning to think about how hospitals can provide resources, and solve problems with primary care and wellness.

02-01:21:38
Kiwall:
Your care is best managed by your primary-care physician. Your health and wellness— your primary-care physician needs to be the source. For us in the acute-care side of the business and the ambulatory-care side of the business—the non-physician side—we realize that we have an aging baby-boomer population. The need for health care is not going to be going down. And believe me, I’m in that population, so I understand that. What we’re seeing is more and more of us reaching a much older part of our lives, and the need for health care is going to rise. So keeping people healthier as much as we can as they age is going to help us manage the health resources for this country. If not, it will infinitely expand as our life expectancy expands; it will get out of control if we can’t manage the wellness. It’s going to be critical that we manage that wellness. Your primary care physician is going to be captain of that ship, and we’ve got to put enough resources around them and coordination around them so that can be done. If not, first of all, the health would degenerate for the baby boomers as they get older, and the costs will get out of control. We have got to make that work.

02-01:23:01
Rigelhaupt:
And you’ve emphasized coordination. And in our last interview, you described physicians wanting to focus more on health and primary care, working with health care systems like Mary Washington Healthcare hospitals. And yet, historically, the AMA has been very suspicious of anything that comes between a doctor and a patient, and at times, hospitals and physicians. I mean, if you think about the level of the AMA and the AHA—have not seen eye to eye. Why has this changed?

02-01:23:36
Kiwall:
It’s the sea change of physician-led, physician-managed; you’re going to see physicians taking a greater role in the overall care of the patient beyond the doors of their practice. That transformation’s taking place now. What’s going to bring together the hospitals and the AMA, is physician-led, physician-managed, and physician-coordinated. [01:24:00] That transformation’s taking place as networks are being built. That’s what’s going to make it better, and that’s what’s going to pull the providers together.

02-01:24:16
Rigelhaupt:
And is part of what something like an acute-care hospital and a health care system can bring to that, is expertise in operations, expertise in efficiencies, that, perhaps, physicians have not practiced for the last few decades?

02-01:24:34
Kiwall:
What we’ve got to bring is effectiveness and efficiency in the operations we have. We’ve got to bring about the transfer of the patient—what happens when you’re ready to go home? Are we done with you then? Or is your next level of care coordinated and set up? Those kinds of things need to happen, and then we will coordinate those resources with the physician’s office. That’s what will help the physician, as a whole, make sure they get the patients they should be getting. Referrals aren’t coming there that don’t belong there because the patient’s time’s wasted and the physician’s time’s wasted. Get the patient to the right person at the right time. That’s what will make the physicians more effective and efficient, make their worlds better, and make the patients’ worlds better. They’ll be healthier. It will make sure we’re only using acute-care resources when we need them. There needs to be a lot more physician leadership involved in the newer model.

02-01:25:35
Rigelhaupt:
Have you seen that taking shape in the day-to-day operations already at Mary Washington Healthcare?

02-01:25:40
Kiwall:
Yes, indeed. That transformation is taking place. The coordination, particularly with the hospital as a service, for the physicians in the building, and the referring physicians. The transfer of the patients and the coordination of care—whether it’s home, to office visits, to a nursing home, to a rehab center, to wherever. Those efforts are becoming more sophisticated every week. You’re going to see that happening more and more and that’s going to make the system better for all involved.

02-01:26:11
Rigelhaupt:
I know we’re a little over the time—

02-01:26:12
Kiwall:
I’ve got get going. I’ve got somebody waiting on me, I think.

02-01:26:14
Rigelhaupt:
Somebody is waiting? Well, I had two more questions. One, to end with. In the twenty-two years, and this isn’t an easy question, what government regulations have had the biggest impact on operations, from your perspective as chief operating officer?

02-01:26:38
Kiwall:
Lately, the biggest impact has been all the uncertainty in the political system in this country. The sequestration, for example, took two percent of our payments from Medicare. And two percent doesn’t sound like a lot, until you find out that you have $250 million worth of billings. [01:27:00] Two percent of $250 million is $5 million; so it is not small. It is those kinds of things. Until national health care is defined, the greatest challenge and frustration is with the uncertainty of the direction. That’s what keeps operations people up at night.

02-01:27:30
Rigelhaupt:
Would it be okay to end with a couple questions about your retirement?

02-01:27:33
Kiwall:
Sure.

02-01:27:37
Rigelhaupt:
So twenty years in, it was in the paper, and recently you announced your retirement. What are some of the things you know now that you wish you knew the first day you started?

02-01:27:50
Kiwall:
I think where the coordination of care was going to end up. And we’re still working on that, but we could’ve been working on that earlier, if, in fact, the country was ready for it. Sometimes you got to get to critical mass before people are willing to change. Unfortunately, that’s human nature, many times. Knowing that over time—knowing more today about efficiencies, effectiveness, and the use of Lean. Putting those tools and techniques in place twenty-two years ago versus the last five years, I think, could have made a difference in operations overall. Some of that is just the maturity of the tools and techniques that are out there and how they apply to health care. To get more and more of the physicians engaged involved in operations that I think we have today. We could have used that twenty-two years ago in a better way. It’s been very helpful.

02-01:29:07
Rigelhaupt:
What are a couple of the achievements that you’re most proud of in your time at Mary Washington Healthcare?

02-01:29:14
Kiwall:
I think the expansion of services and facilities in Mary Washington Hospital. Clearly, the Stafford Hospital project, overall, I think is a huge achievement. Being part of the expansion of services into the region, the improvement of access, and that not everybody can go to a single building. That’s not what they need. To work with the board and other leadership people to improve the access in the region, and to be part of the fact that we improved services here. To read in our documents, or even in a newspaper, a trauma that’s occurred; it was brought to Mary Washington and someone’s life was saved. [01:30:00] Knowing full well that, if they had to wait for a helicopter or if they had to be taken somewhere else, they wouldn’t be alive today. The fact that I had my hands in helping make sure people were better and that people survive a health care crisis that they wouldn’t have survived that crisis if my hands wouldn’t have been in some of these things. That’s extremely rewarding, overall.

02-01:30:38
Rigelhaupt:
You have hinted at someone who is chief operating officer or in senior leadership at a hospital is always thinking ten or twenty years out. What are some of the things you think will be in Mary Washington Healthcare’s future ten or twenty years out?

02-01:30:58
Kiwall:
Patient’s care will be 100 percent coordinated. And your life, when it comes to access to health care, will be better than it’s ever been. The decisions you make in how you live your life and your lifestyle will help determine whether you can live that long life. But Mary Washington Healthcare and the systems in place will make sure that you have every opportunity to have a good quality life. The only thing that will manage or change that will be your own personal decisions. That is where I see it ten years from now.
[End of Interview]

css.php