DAVID S. BRODY
Past Chairman, Board of Trustees
Pitt County Memorial Hospital and
University Health Systems of
Eastern Carolina

August 16, 2000

Interviewer: Beth Nelson

Beth Nelson: I know quite a bit about your background over the years, but for the purposes of this visit, start with your background, your growing up years and how you came to be associated with the hospital.

David Brody: I was born in Sumter, South Carolina, which is where all the Brodys came from originally and I went to the University of Pennsylvania and when I graduated from college I came here and went to work with my family in 1972. I worked in the store downtown and I was the downtown manager and bought some merchandise for the store. I got married and lived here in Pitt County up until 1977 when I moved over to Kinston. That is a little bit of my background and my first encounter with the hospital was actually with the old hospital. When we were first married I was out of town on a business meeting and when I came home my wife wasn't home and in turns out that she had been taken to the hospital with a miscarriage. This was the old hospital which is now the County complex and I went in there and finally found her because she didn't have a room. There were no rooms available and she was in the hall along with other people. She was on a gurney and there was paint peeling down from the ceilings and paint peeling down from the walls and that was my memories of the original Pitt County Memorial Hospital. Two years later my first son was born in the brand spanking new PCMH and it was like light years away from that old building. Most people in Pitt County probably don't remember that.

My first appointment to the Board, I think, was in 1983. Someone had been appointed and within like three or four months couldn't serve because of health problems and so I was appointed to take his place by the UNC System as one of their appointees. I served for six years up until 1989 and then I went off the Board and then somehow or another they talked me into coming back and I have been here since 1990. At that time you were appointed to two five-year terms. I served two five-year terms and all total I was on the Board for sixteen years. I got a one-year break in the middle.

Beth Nelson: I wonder if that's a record?

David Brody: I think it may be.

Beth Nelson: I can't think of anybody I have ever heard of who has been on for that long.

David Brody: I think you had people who have been involved ex-officio like Kenneth Dews or Charles Gaskins who have been there forever but those would be the two guys who I know. Even though they didn't cast a vote they sure had a lot of influence.

Beth Nelson: Leadership positions-you chaired some committees and it seems like you had another position prior to being Vice Chair.

David Brody: Over the course of the term I was Chairman, Vice Chairman, Chairman of the Finance Committee for a long time. I think there were some statutory limits as to how long I was on that, I was Secretary. I have been on just about every Committee there is. I never thought about it but I have been the Secretary, Treasurer, Vice Chairman and the Chairman, which are the four offices I have been in. Have been in each of them several times.

Beth Nelson: Lets talk a little bit about what you feel like the hospital means to Pitt County and the region.

David Brody: Well, in Pitt County it is almost hard to calculate what it means, besides being just an amazing facility. For a community this size to have a medical school/tertiary hospital is just a blessing in itself but this is the main economic engine that serves the community and has done a lot to elevate the quality of life here on so many fronts. I think we did the calculation that the medical school/hospital complex generated something like 20% of the economic dollars in the County and that is a huge number. In the region again you cannot begin to calculate the effects in the region. I think it is more relevant to me being out of the county than some of the people in Pitt County. Just this past weekend I was driving into Morehead City and I see the EastCare helicopter landing. You know they were there for a mission, as they just don't take the helicopter down. As I walked into the hospital anytime I came I saw people from Kinston that were there with family emergencies. We had stores in Jacksonville and New Bern and Rocky Mount and I was always encountering people that would tell me stories of how they had some miraculous event here at the hospital. It is everywhere and you talk to people in Windsor or just as you get out and about it is all through this area and it is always positive. Somebody said they were so glad it was there as his father or mother would have had this or that or my granddaughter wouldn't have been this. It is constant and pervasive and it is amazing that in twenty years it has managed to have such a total impact in the area.

Beth Nelson: Think about some significant memories that you have over the years. Some things that help to describe the texture and the feel of this place and what makes it special. Some people that shared things that were funny, some people have shared things that were poignant, whatever comes to your mind about events or people who have really made a difference.

David Brody: There are so many people that have made a difference. When you go to the employee dinners in November when they honor people who have been here ten, twenty years and you see it there, I think, it brings it home to somebody who is not a hospital employee. When there is somebody like a Board member or the general public, if they could go to that meeting and see the sense of pride that so many people have in having been affiliated with this institution. Back in the eighties they instituted a little slogan that PCMH stood for "People Care More Here" and I think it really comes across that way. People feel like they have gotten good care. I had to address that dinner and I was saying that there are no unimportant jobs in the hospital. When the patient comes in the front door of the hospital if the lobby is not clean then the people don't have a sense of faith in the institution. If the halls aren't clean, if the rooms aren't clean, people don't have confidence in the institution. It goes from right like that when you walk in the door everything has to be right. We are not perfect but it is an amazing institution because I have had an opportunity to go in a lot of hospitals in Durham, Chapel Hill and other towns throughout and I don't have the sense that I have when I walk into PCMH with things running as well as they do and I think that comes across and there are no unimportant jobs in the hospital. I think that the employees have that sense that the Administration and everyone feels that way. Some days you don't feel like you are taken at full value and maybe you taken for granted but I think on the whole people that work at the hospital know that they are about some important business and have a sense of purpose and that comes across and that is part of the healing process. The employees have confidence in what they are doing. The people who work there have confidence and that comes across to the patient because that is part of the healing process.

Beth Nelson: Let's talk about some of the things you were sharing a few minutes ago before we were rolling the tape. One of the things you mentioned was an event when I guess you were going through the struggle for privatization.

David Brody: You know, one of the more interesting things about in being Chairman that you see that you didn't see even as a regular Board member is getting to know a lot of the Administrative group and doctors in different perspective because you spent more time with them and saw them more in their work environment than in another environment, Sally Lucido was an institution in her own right in the Executive Suite, during the negotiations on the privatization of the hospital, we had to do numerous legal documents and numerous letters and whatnot. One time we were redrafting what was a pretty important document and we were up in the Administrative Suite and Sally had Nancy Aycock, the attorney, on one side of her, Debbie Davis on the other side of her, and me standing behind her. We were doing a document and making word changes and all three of us were talking at the same time and Sally was able to sit at that computer and type out everything we were saying but synthesizing the best of each of us. This went on for several minutes and it was several pages and when we got through and reviewed it she had done just a perfect job and I was just awestruck that anyone could do that-I mean it would have been one thing for somebody to take dictation over a computer and another thing to have someone else editing, but to have three people spewing different things out and Sally synthesizing was just incomprehensible to me.

You saw a lot of people in that environment. I think that people don't realize what a job the Chiefs of Staff have to do because they are in there early for meetings, they conduct their regular jobs as a physician, they are having to meet with other doctors and mediate between doctors. They have to mediate between the doctors and the Administration and it is a tremendous amount of work that the Chiefs of Staff do. I think that is an interesting thing to watch and the different personalities of all these doctors in that position has been kind of interesting to watch.

Beth Nelson: They also have to maintain their clinical capabilities because quite a few of them continue to carry clinical work. It is just amazing to me that you could do all the administrative work and have the energy and ability to stay up-to-speed in your chosen field.

David Brody: I think one of the things that has changed recently and I think is kind of a good evolution is that the doctors, you know whenever you go to any of these hospital conventions they are talking about medical staff relations and it is a difficult issue and it is always, they say, an impossible issue. It just seems like there must be some way to do a better job of that, I think we have hit on something semi-groundbreaking but if it becomes institutionalized and really goes forward as a start it could be a big thing for the future is that I challenged Dr. Bolin to have more input in the Board meetings on physician issues. I kept saying as it would come up and I would challenge him and say you are not giving us enough lead with budgeted positions and he would say that the problem is that physicians don't talk with one voice, we have 500 physicians, probably 800 attending and so they formed something that they called the "Past Chiefs Committee" which I always called the "Wise Men Counsel" because they thought they were so smart but this became maybe a filter to get physician opinions and put them to the Administration in a proactive solution. They would say that here is the problem that we see and here is the potential solution to it and the Administration wouldn't take this as a threat or but more as an opportunity to improve relations and to do something better and respond quicker. A lot of times they might respond but it could take nine months. So, we are hoping that it is an innovative way to help with staff relations, but also to come up with a clinical strategic plan that would dovetail with the hospital's strategic plan so that the actual physicians out there felt like they had input into what was going on in the departments on a strategic basis. It is not to say that it was perfect and that there was total agreement on everything but at least everybody could get their priorities straight. I think that has been a big step forward in the last two years.

It is interesting, I bounce that off of doctors in other hospitals and they all say boy that is a smart idea and that they had never thought of something like that and that they had never heard of it anywhere else but they thought that could may be something that could become a model in other hospitals and that it was a pretty good idea.

Beth Nelson: Just a few minutes ago you mentioned some of the things that occurred during the privatization process and I think nobody would question that you have had a lot of influence over the hospital's growth and development over the years but when I think of areas that you really took a leadership role in, the privatization certainly has to be among the top if not the top accomplishment I would see being credited to you. Let's talk about some of the things that you remember from that process.

David Brody: The privatization process was really a longer process than people realized in that the discussions went back to even the eighties when Phil Carlton was the lawyer for the hospital and, of course, he became a Supreme Court Justice. There was a study commission that Dean Laupus had actually gotten me appointed to for the survival of small hospitals. I didn't realize this until later as I look back on it and it is really is such a strange thing that the seeds were that far back but that was back in the eighties. One of the things that came out of that small hospital survival commission, because they were worried when DRGs came in, people didn't realize that President Reagan was elected and they switched to the DRGs (Diagnostic Related Group) payment system, automatically hospitals all across the state emptied out because you weren't going to get paid if you kept people in there too long. There was a real fear that the hospitals were going to go away, a lot of small hospitals. Of course, a lot of them have become not viable. Anyhow, I was on the study commission and out of that study commission came the laws that enabled the privatization of a hospital. I hadn't even thought about that until after the process really. Judge Carlton recommended even then that we go through this process. Of course we knew that at that time it was just better not to even talk about it. It was politically not on the table. Then when Kelly Barnhill was Chairman it was brought up again because we saw the need arising to be able to do things out in the region and partly with physician groups and given the flexibility that we saw going on in other areas and to be more competitive and to take us where we needed to go. It was finally under Lawrence Davenport that we made the decision that we needed to go and do this and Lawrence Davenport got the ball rolling with that and we felt that under his chairmanship because he was a well-respected man in the community that was how we would start out. It became a much more vigorously contested idea than we had thought and we got bogged down in that and I think that when we had to change from Lawrence to me as Chairman I think it was time for a fresher approach and we both agreed that the case needed a break. Since I was a new Chairman and said we were not going to go back to the way we were going about it and I decided that it was worth it but the hospital had taken such a beating in the Press and on the airways and unfairly because our side wasn't really being presented clearly so it was time for a change. So, we made a real strategic change and I think I played a little harder ball with the commissioners than Lawrence did and we were able to get it through shortly after I became Chairman but a lot of things had been put in place.

One of the nuances of the whole process was that all of the TV stations had recently been sold, particularly Channel 9 and they went to a hard-edged style of reporting. They were all trying to have this intensity about their reporting. That doesn't mean that it was any fairer, that meant that they were looking for or trying to create even a negative and so they were all in competition for who could make a story out of this as opposed as to who could present the facts and that really inflamed the situation more than it needed to be and I think that was just an unfortunate happenstance in the process. It was just something we had to deal with as we went through the process. I had been on the hospital Board for fourteen years and had never been to a called meeting of the hospital Board and in my first few months I think we had six. I thought that after that privatization I would never call one again. I think they actually did have to call another one at another point when we were buying a hospital. Events kept coming together that made the whole process more difficult. Columbia HCA which is a big New York Stock Exchange Company decided to sell off a group of hospitals in the Southeast. We were approached to buy Tarboro. Here we were going through privatization, if we could get private it would allow us to buy them. It was a perfect example of how the privatization would work for us because we could finance it off of their balance sheet and our balance sheet but if we couldn't and if we were not private it would make financing a lot more difficult and a lot more expensive. So, in the middle of this we had to go to the County Commissioners in closed session and tell them that we had this deal that we were working on with Tarboro, that we were going to buy this hospital, and ask them for a lot of money. It was like some of them just went crazy. If we hadn't bought the hospital, Duke was lined up next to take it. Here, instead of us having owned Tarboro, Duke would be in Tarboro with that facility so it was a lot of balls up in the air at one time and at the same time we knew that Chowan was on the backburner and we had just done a deal with Ahoskie. Ahoskie was a classic example of how privatization would help. We had to put together this real convoluted structure to make the deal with Ahoskie work and now under privatization we were going to have to reorganize and make the think much more streamlined. There were just so many things that started just coming together which made the whole time complicated. If we had it spread out over three or four years it would have been easier. All of this happened in a six to eight month window and I don't think people realized just how much was going on in that one little time zone.

Beth Nelson: I didn't realize that Duke was coming in the wings on the Tarboro issue, was that a real bugaboo out there or was that something that we thought if we didn't jump on this opportunity that they would be the next most logical people to?

David Brody: Well, the reason that they were the next most logical was what was happening was that the deal was brought to us through NOVANT. NOVANT was trying to put together a group to buy these several hospitals in the Southeast. Originally NOVANT wanted the hospital in Raleigh. You start talking these kinds of numbers for buying hospitals, Duke paid $200 million for the one in Raleigh, so the original deal was NOVANT was going to take the hospital in Raleigh and we were going to take Tarboro but if we couldn't do it, they were going to broker it off to Duke or Charlotte or somebody else. Duke and Charlotte were both on the backburner to take that hospital or it would have even gone to Centura up in Norfolk. So, you had to get somebody who was big enough to pay $80 million for a hospital. So, who were the likely suspects-you had Chapel Hill, Duke, Centura - those were the names, so we were first choice. NOVANT was nice enough to come to us but if we couldn't do it they were moving on because this deal was going to go down in a certain time zone. What happened was that NOVANT had bought Charlotte Presbyterian and they thought they were in good condition and in the middle of all of this they found out that they had some skeletons in the closet down in Charlotte, the financial situation in Charlotte, and they had to back out of the deal in Raleigh and that's how Duke wound up with the Raleigh Community Hospital. There was a whole series of events in there so we definitely had a lot of pressure. We had to make a decision, we had to put together financing in pretty short order and we had to get a decision from the County Commissioners. So, in the midst of all of this between the County Commissioners having to make this privatization thing we threw in the Tarboro deal in the middle of all that behind closed doors and because it was a New York Stock Exchange company that we were dealing with there was confidentiality with it so we had to keep those things quiet by law and the County Commissioners had to keep it quiet by law because before we could discuss with them they had to sign confidentiality agreements. There were a lot of dominoes in there and interestingly enough we had to explain to the Commissioners because several of them wanted to run and tell the Press about this but the liability we had if this deal fell through and the magnitude if HCA stock went down $5 because of this disclosure we stood liable for a billion dollar lawsuit because of the loss of market value. That was a pretty good incentive for everybody to keep the deal a secret. That was what was going on and if you would look at the timing of all these hospitals involved, we had several of them in rapid order there about eight months later.

Beth Nelson: Let's go back to Ahoskie, you mentioned the fact that if we had been private at the point it would have been a much more streamlined process. Are you talking about a twenty-five year lease type deal is that what you were saying?

David Brody: Well, we may have done it differently but it would have made things a lot simpler. If we had been private when the deal with Ahoskie was on, it wouldn't have just been the privatization it also would have been the corporate governance structure. We would have had a governance structure that would have had the ECHN and the ECHN could have bought it as a direct lease but we had to form almost a triangle with the lease and their foundation and all that stuff. We could have got it much simpler had we had the corporate governance structure and the privatization-they kind of went hand in hand. When we went private, we got the privatization done but we maintained the same corporate governance structure because it was a politically sensitive thing that would remain PCMH and within very short order we were going to buy all these hospitals, Chowan in Edenton and now you have Ahoskie, Roanoke-Chowan and your going to have Bertie County, Dare County and we needed to organize in a corporate structure that could facilitate running all these different lines of business-and the home health business-but PCMH is still the mother ship if you will and it is still the anchor to the whole system but we needed the University Health Systems structure. So, here it was, we had just gone through privatization and about three months later we came to this realization and debated among the leadership groups and the Trustee groups on how can we go back to the Commissioners and ask them to put forth the change in corporate governance. We finally came to agreement that it was the right thing to do and the worse thing they could do was to tell us no. We went up there and told them it was the same company with the same everything else but we are going to be running it like this and if its going to look like a duck and walk like a duck why don't we just call it a duck. So, we went back up there and got the same 5 to 4 votes that we had before and fortunately we got the governance structure through. We knew that there was going to be a change in the County Commissioners and the possibility that the future would not be good so we went ahead and did it and it was the right move. It is interesting to look back on all of that and here it is almost three years later and you don't hear anything about it. It is just like we said it was going to be. The patients cannot tell any difference, people living in the community cannot tell any difference, people living out in the region cannot tell any difference. The only thing is now the hospital itself is able to govern itself more effectively, able to do things financially that we couldn't do otherwise and everything is running a whole lot smoother and more effectively. Interestingly enough, the Monday after the County Commissioners vote, I asked Dave McRae if I could come to the Monday morning staff meeting that he had and I had never been to one before and I haven't been to once since. I went in and I said to be careful what you wish for. We are like the dog that caught the car and now what do we do with it? We wanted to be private, we wanted to have this governance structure, now we have got it and it is our job to prove that we do right and to make the most of it. I threw the challenge down at that meeting and Jim Ross picked it up. I challenged him, I told him people have been merging systems, when you go to health care meetings you see where people have been merging systems and that they never had the reaping of any benefit from it that they never cut costs appropriately, they never got more efficient. I told him that for us to buy hospitals was really wasteful if we can't do a better job with the hospital and if they don't come together and make a better system then why have we done it. So, Jim Ross came back with a plan to myself and Buster Humphreys. We asked him to show us how he could do a good job better and interestingly enough what happened was they were able to take out about $18 million worth of cost structure and it was just a lucky thing that we challenged them and that they were able to do this because what happened was the Balanced Budget Amendment of 1997 cost us over $40 million worth of reimbursements through the system. So, the proof of the whole thing that was put together was we are financially stronger because we were able to go private, we were able to reorganize, we were able to buy these hospitals under this structure and then we were able to take costs out of the system and still maintain high quality care and be financially stronger. If you look at South Carolina, two-thirds of the hospitals in South Carolina have lost money. A significant number of hospitals in North Carolina, particularly eastern North Carolina, last year lost money because of the Balanced Budget Amendment. We have had a great year and it was because I could point you right back into this whole sequence since privatization why it all happened. I don't think the public really understands the whole sequence of that.

Beth Nelson: I didn't myself realize the impact the Balanced Budget Amendment had on the hospital and privatization.

David Brody: The hospital and the institution has been lucky, as we have had a lot of things that have happened kind of at the right time. You know, some of it is luck and some of it is skill. I think you have had an Administrative Staff that knew the Balanced Budget Amendment was going to cut reimbursement. Now do some people sit back and let it happen to them or do some people like our Administration became proactive? They knew it would cut reimbursements, how could we cut costs to be more effective. A lot of it was in purchasing; a lot of it was done in scheduling. The two biggest cost centers were Personnel and drugs and supplies and so we were able to do a better job in that. During the privatization they said rather than cut jobs they were going to eliminate people and they used that fear mechanism but you look out there and hospital employment is higher than it was prior to privatization. I think it has more effectively challenged Administration to be more effective with the money and it was not what you spend or how you spend it and the proof is we are doing very well. You look around the area, Onslow County lost money, Wayne County lost money, last year for the first time Lenoir County had a bad year, all across the State, Duke had a horrible, UNC a horrible year, PCMH performs better than any hospital that I am aware of and I am sure there are some that I am not aware of, but I think the seeds were sown through the privatization deal and the fact that we challenged Administration to cut costs and become more efficient which they did and so all of our hospitals did real well.

Beth Nelson: One thing that you referred to was when DRGs came in. You had come on the Board about that time. I remember a lot of hand wringing and being afraid that we were going to have trouble just surviving under DRGs and we changed much of the way we did business as a result of that. Would you see what happened with the Balanced Budget Amendment was it that big a change would you say?

David Brody: No, the DRGs were the absolute water shutdown. The DRGs had some subtle effects on this institution that you wouldn't think about. DRGs came into effect and enforced about the time that a lot of the new clinical services at PCMH were coming on to strength. So you had hospitals all around the region and in the State where the occupancy rates just went plummeting. They might have been running at capacity-full capacity, I remember Lenoir Memorial had just built a new floor and all of a sudden they were 25% vacant and had to just seal off the whole new floor and this had gone on all over the State. What was happening was PCMH wasn't really emptying out because they had all these new services coming on. Out in the region the doctors said we were taking their patients and so there was a resentment that built up in the region amongst the physicians out there because they felt like PCMH was stealing patients. It was that we now had services that were not being provided in the region and the things people were going to Duke and Raleigh for they were now coming to Greenville for and it took a few years for physicians to understand that that was not really what was going on.

Beth Nelson: Let's talk about key individuals, I don't want you to name the people yourself, I just want to make sure that there is not somebody we have overlooked in this process. I have a long list of people that I consider to be critical folks but every now and then I stumble across a name I hadn't heard before. If there are people other than those you have talked about-you talked earlier about we have had very little turnover in the CEO position and the right people in that key role both for the hospital and the school of medicine. Please revisit that so we can get it recorded.

David Brody: I think one of the keys to the success of this hospital has been there has been a mission. The medical school had a mission and the hospital had a mission and they overlapped and that has always been the driving force. That has always been the mainstay, the purpose and the light that people went to. It has always been a litmus test. What I have always been proud of is on my Board has been when a decision was made when we had a question about whether to do this or not do this, the test was did it fill the mission. There have been times, numerous times, where we have done things that were not necessarily the best financial decisions. They were strictly a mission decision and we have been focused and driven under this and it has been the Board and the Administration and the Medical School and that has kept everybody going and it will keep us going. That is how we are going to be successful is keeping that focus on that mission of service. I think that there is no doubt that you know sometimes it may sound corny but we are a very altruistic group because we are focused on mission. This is a non-profit institution and so people are focused on that mission and what has really held us is in the fact that we have only had two CEOs in this whole time period, two very good ones, and we have only had two Deans and everyone has been brought into this mission and they are routed into having to work in having to build this thing because you realize where we started from. We started from what I talked about in the beginning-from that old hospital over there and people who have been here and have that sense of history in having had to fight to get this. I think our big challenge in the future will be can we evolve the new leadership group who doesn't have this history that didn't come up and build this whole thing and our mission, can we put the mission into the new person. If you went out and hired a new CEO to come in from another place, he or she may not have the sense of this mission and of our history. I think that it is a very critical, critical part of who we are, what we are and that is probably our greatest challenge. The institution is established, the momentum is, the building base is here for sure and it is a very strong institution that will last a long time. How we respond in the future. Can we keep that sense of purpose? Can we keep that sense of mission? That is the real test of where we go and who we are in the future because that is the one thing we really don't want to lose. That has been what has made this place unique and special is that it does have a sense of mission.

Beth Nelson: You also mentioned the fact that the people in key leadership roles were the right people in those roles at that time. Lets revisit that just briefly and talk them because those folks are people you worked shoulder to shoulder with in your tenure. What do you see do you see is the strength, what made those people the right people at that particular time?

David Brody: Well, there are so many to talk about. You know, you can go back to Kenneth Dews and being a man of the people and being such a part of the community and so focused on trying to build the institution back twenty to thirty years ago. That whole group that I guess were kind of like the fathers of the modern institution. Jack Richardson had gotten the institution to a point and knew that to take it to the next level, he had to turn over the reigns to someone else. It is like climbing a mountain. You go up step by step but sometimes you have to scale a large wall and that in an institution, sometimes you have to take yourself to another set of skills, a higher level of skill sets. Along the way, a Chairman that I can think of that you had was Bob Spivey who would have been Chairman for two years but relinquished it because he felt the need to start the process and he brought Kelly Barnhill in because we needed a Pitt County Chairman at that time. Lawrence Davenport who started the process of privatization. My business background, I think, because of really more than leading the privatization fight was the reorganization and restructuring of how we were organized and how we functioned as a Board and its governance structure. You have a guy like Dave McRae who is running with the job but he has kept that sense of purpose and mission and is such a skilled people person that he is able to work with the doctors. You have a very unique situation here with private physicians and medical school physicians and there is such a balance with the community, with the private doctors, with everybody, and Dave has the unique personality to deal with people. You just have the right people in the right places that come along up through the ranks. We are very fortunate. I don't know where to stop there are so many.

Beth Nelson: You talked about challenges for the future when you talked about trying to maintain that sense of mission about being the driving force in our decision-making and that kind of thing. Does anything else jump out at you, anything you want to bring up that maybe we didn't cover?

David Brody: You know, at my last meeting I did a little speech that I think Dave liked and it was that it is not that difficult if we keep a focus on the mission, if we keep the focus on quality health care, the people are going to go where they sense they get the best care. I don't think that we are going to have problems if we deliver high quality care. People are going to come here and we are never going to have a problem with that. If we have a sense of our mission we will always be moving forward.