Intro: The following SHSMD Podcast is a production of DoctorPodcasting.com.

Bill Klaproth (Host): On this edition of the SHSMD Podcast, we have a SHSMD Connections Keynote Preview for you as we talk with Dr. David L. Schreiner. The keynote is on Thriving Against the Odds: Using Supercharged Engagement to Navigate the Path to Rural Hospital Sustainability. Many of our rural hospitals are in crisis right now, facing many challenges. We're going to address that at SHSMD Connections 2024 with Dr. Schreiner. It's going to be a great keynote. This interview is going to be really good. Please stick around for the whole thing. You're going to learn a lot. Dr. Schreiner is awesome, and the keynote is going to be awesome at SHSMD Connections 2024. So, let's get into the interview right now!

This is the SHSMD Podcast, Rapid Insights for healthcare strategy professionals in planning, business development, marketing, communications, and public relations. I'm your host, Bill Klaproth. With me today is Dr. David L. Schreiner. He is a PhD and National Leader in Healthcare Leadership and President and CEO of KSB Hospital in Dixon, Illinois. We're going to talk about his keynote coming up at SHSMD Connections 2024. Dr. Schreiner, welcome to the SHSMD Podcast.

Dr. David L. Schreiner: Bill, thank you so much for having me. I'm excited to spend some time with you.  

Host: Absolutely. And we are looking forward to your keynote at SHSMD Connections 2024 in Denver, Colorado, October 13th through the 15th, as we talk about this great subject. Basically, how do we supercharge engagement to help navigate a path for our rural hospital sustainability, which is very important. So, Dr. Schreiner, if we could just set the stage first, what are the current challenges that rural health care is facing?

Dr. David L. Schreiner: Bill, I believe many rural hospitals are still recovering from the impact that the COVID-19 pandemic had on our balance sheets. We are approaching positive margins, although there are still a number of our friends and colleagues in hospitals around the country that aren't back to break even yet. And the implication of that is even if our hospitals started with a strong balance sheet, we have had to spend down cash because of some of the challenges that were a result of the pandemic. So, it's a difficult time as we look at finding capital to reinvest into our organizations.

Host: Yeah, that makes sense. And I'm wondering too, being in a rural setting, you probably don't have a lot of larger companies coming in to partner with you, if you will. Has that put a stress on your system too, because you're unable to share costs?

Dr. David L. Schreiner: It's a double-edged sword, Bill, which I think is really interesting. So, the good news in many rural communities is that we have a wide array of smaller companies that are in our communities, and we don't necessarily have that one employer that has, you know, 10,000, 5,000 employees. So, the good news is when one company leaves town, it doesn't decimate the economy. The bad news is many rural hospitals are either staying the same in overall population or they're declining, and both of those cause stress on our hospitals.

Host: So, let me ask you this then. So, you kind of have to foot the bill for everything, right? Because like I said, you're not having a lot of bigger hospital systems wanting to come in and merge with you. Is that correct?

Dr. David L. Schreiner: Well, I think many rural hospitals are attractive to larger systems, but that is so much based on geography and where the hospitals are around the country and, of course, the history of that hospital's ability to serve their community over the years. So, I think there are some rural hospitals that are very attractive to our larger system partners, and there are others that are in a very difficult situation and geography has a great deal to do with that, Bill.

Host: So for the ones that are in a difficult situation who don't have a bigger health system looking to merge with them to share costs of, say, legal, human resources, et cetera, how does an independent hospital deal with such a heavy overload then?

Dr. David L. Schreiner: It really is a distinct advantage for those of us that are now independent. And it's one of the reasons that our hospital is going through affiliation discussions as we speak. The way that we work with that is, first of all, we do try to reduce expenses. Of course, we've gone so far over the last three or four years that we have to be careful about not having those expense measures impact our quality and impact our patient and employee satisfaction.

But some of the things that we can look at are things like bringing specialists into the community on a part-time basis. If we have larger systems that are close to us, some of their physicians might have capacity. We can have those skilled professionals come into our rural hospitals. Maybe it's a half day a week, maybe it's a day a month, and see patients here in our town. And the hospital benefits from the ancillaries that might be ordered by those physicians and even potentially from some outpatient surgical procedures. So, one thought is to look for services that are not offered today and see if those can safely be offered in our community.

Host: So if you bring in specialists, you kind of stop leakage then to the bigger markets, is that right?

Dr. David L. Schreiner: That's exactly right. And also, what we find is in our rural communities, the people want to receive care closest to home. They're not interested in traveling. The hospital that I'm a part of is about an hour and a half west of Chicago, Bill, and our people don't want to go into the city. They live in a rural area because they chose to do that. They continue to choose to do so. And it's a different world. And so if we can provide those services very close to them, that's a win for our community and for our patients.

Host: Absolutely. So Dr. Schreiner then, is it also another strategy to make yourself potentially available or look for opportunities to partner or merge with a bigger hospital system? Is looking for a partnership or an affiliation, is that something you think that potentially rural hospitals should go after as well?

Dr. David L. Schreiner: I think that it is incumbent upon our rural hospital leaders to educate their board about options, Bill. And this is something that I started as much as 10 years ago here at KSB Hospital and educating our board about what affiliation and mergers and partnerships might look like. Every community has to look at their own situation and decide whether affiliation is a viable option for them or something that they're interested in. And the timing has to be right for that community. I don't believe it can be put out as a one-size-fits-all. But I do believe, for those of us that are independent, that we do have to look towards educating our board members, because it's a very difficult decision to go down that path.

A quick example here is our hospital was founded in 1897. And so when our board made the decision in January to seek out an affiliate partner, that's a very difficult vote for our board members. It can impact their businesses, it can impact their relationship with their friends and colleagues in the community, and it's a tough decision to make. However, we made the decision that for us, the best way to provide those health services in a viable way to our community was through an affiliation. That certainly doesn't mean that that's right for every hospital.

Host: Yeah, that's a good point. I would imagine there's a point of pride, as well being independent.

Dr. David L. Schreiner: Yeah, we want that pride, right? We've worked hard to develop that, and we also talk about the idea that what really matters is the care that's delivered within the walls of the hospital, and if the sign changes, that is a big change in the community. But we still have our friends and neighbors taking care of friends and neighbors, and that's important in a rural space.

Host: Yeah, that is. And that's what is really important to remember. Dr. Schreiner, I hear a lot about payer mix, if you will. Can you talk about that and how a positive change in that can really make a big difference? What should we know about that?

Dr. David L. Schreiner: Well, you mentioned earlier, when we do have new industry or new employers come into our community, we love commercial payers, and that's a positive, Bill. When we look at rural communities, what we know is the statistics show us that our communities are getting older, they're becoming less educated, and that's difficult in a community. And so when we have a very slight move from medicaid or self-pay to commercial insurance or the flip side of that is we have if we have a move from commercial to Medicare, then that changes the hospital's profitability. So, small movements in our world can have a very big impact.

Host: Obviously, you probably don't have a lot of control of bigger companies moving into the market. But is there a way you can address that or work with that or change that on your own?

Dr. David L. Schreiner: I think it is incumbent upon us as leaders in rural hospitals to have wonderful relationships with our business leaders in our communities. And that's something that just takes a month by month, quarter by quarter approach for myself or members of our executive team going into these companies and saying, "How can we serve you? What are the things that you're looking for? What are the things that we can do to help you?

And then, the next step beyond that, Bill, is the concept of direct contracting. Are there some things that we can do around wellness? Can we come into manufacturing plants, for example, and offer blood pressure screenings, offer podiatry checks? Can we do direct contracting around things like mammography and colonoscopies? Are there things that we can do to help lower our friends and colleagues that are in industry, in our area, in business? What can we do to help their bottom line at the same time that we keep those people here in our hospital community?

Host: Yeah, community outreach. That seems like a really important thing to do, to get out into the community and offer those things. So, that sounds like a great strategy. Let me present a scenario to you, Dr. Schreiner. Say you're an independent hospital in a smaller market, and say there is another independent hospital in a smaller market fairly close by, but that one is affiliated with a larger hospital. What types of problems does that present and how do you deal with an issue like that?

Dr. David L. Schreiner: Yeah, that's such a good question, Bill. And in our scenario, we made the decision that we could not have enough profit in order to recapitalize the way that we were used to doing. In the past, we put about $7 million a year back in capital into our organization. We were simply unable to do that over the last three or four years. So, part of the idea of finding an affiliate partner is to have a big brother that can help in some of those capital needs. And if that happens at one hospital in the community and someone a few miles away does not have that cash infusion, that can potentially erode market share in the other community.

Host: So, you mentioned cash infusion. Let's talk about cash flow for a minute. That brings up a good point. So what if cash flow, and we know that our rural hospitals are struggling, what if cash flow becomes an issue? What are some strategies for health care leaders in that situation?

Dr. David L. Schreiner: I believe we've all done a really nice job over the last several years to try to reduce our expenses in every way that we can. Some of that might include outsourcing of services. So, one example of that, Bill, is we outsourced our revenue cycle. And because of that, we got better results for less money. It may not be right for everyone, but it was a move that was right for us.

We also have to look at the organizational structure that we have. It's common to have multi department directors in rural communities. So, in the past, where we might have a director of medical imaging, a director of laboratory, and a director of pharmacy, we might have one leader that is over all three of those departments. We want to invest our dollars closest to the patient. And to the people that are closest to the patient, and then remove as much additional expense as we can. The challenge with that bill is there's only so far you can go on that. And at some point, you begin impacting quality, patient satisfaction. And just as importantly, we started this podcast today talking about communication. That employee satisfaction is so big, and making sure that we stay connected in a meaningful way to the people that are closest to the work is so important.

Host: Yeah. That brings up a really good point. It sounds like you do have to get creative when you have to. How do you keep staff morale up, if you will, as you talk about that, Dr. Schreiner? I'm thinking about your staff. They probably perceive or know or hear things like, "Oh boy, we're in trouble" or, "Oh boy, things aren't looking very good here." How do you address the staff if there's a perception that we are struggling? This is not good. How do you deal with that?

Dr. David L. Schreiner: That's such a good question. And when we made the decision in January to look for an affiliate partner, I made the commitment to our employees, first of all, that they would hear it from me first. So when our board made that decision, Bill, on the next day, we had a meeting with our key physician leaders at 7:00 a.m. We had a meeting with our leadership team at 8:00 a.m. And then, we had, I think, it was three or four 30-minute sessions for all employees through the rest of that day. So, I wanted them to hear from me and not from the media or anyone else that our board had made the decision to seek an affiliate partner.

I also committed to them that they would hear from me once a week about the progress that we were having. And that transmission, that video that we did, it would be transparent and it would be authentic. I would tell them as much as I could about where we are and then what the next week looked like. The challenge with all of that is because non-disclosure agreements and other things, we can't provide nearly as much information that we want to. But I think if we keep that communication line open and we realize that there's a huge amount of anxiety over something like an affiliation, then we have a better chance of keeping people connected to our mission and making sure, as I mentioned before, that the people that are closest to the work are still going to be needed and necessary and important in the delivery of care in our community.

Host: So important. And what you said certainly helps retention as well, which is really important. And when you keep a really good staff, that also improves patient outcomes as well. So, there is a trickle down positive effect with positive communication as you said. And I love how you use the word authentic. Once a week, you're up there, you're telling them how it is, so they don't feel like they're in this alone. They feel like you've got their back. Is that right?

Dr. David L. Schreiner: I think that's so important. And as I've been in my career a little bit longer, I've learned it's okay to say, "I'm scared, too." And that's anxiety-producing. And these are the things that we're doing to make sure that we have a great outcome for our community. But I think understanding what some of their fears and concerns are and answering questions, we made sure that we put out a place on our intranet where all employees could ask questions. And in that Friday video that I put out, I answer those questions that come in that week. So, I think that that responsiveness, that accessibility, and then there's also a lot that goes towards telling people how grateful we are for the work that they do. How grateful we are for the work that they do is so important.

Host: That is really important. And when we talk about supercharged engagement, that's one of the key facets, I think. This is going to be a great keynote at SHSMD Connections 2024. I can't wait to see it. And anybody that's in a rural healthcare setting, please come see Dr. Schreiner at this keynote at SHSMD Connections 2024.

Can I ask you just a kind of a couple of wrap ups here? What are your key takeaways from you on all of this? For someone listening to this that might be in a similar situation as you, can you just share a couple of your main key takeaways?

Dr. David L. Schreiner: Sure. I have three that I'll with. The first is know your community. One of the blessings that we have as rural health care leaders is we're a part of our community. We often live in our community. Understand what your community concerns are, understand what your strengths are for your organization and play into those strengths and address the weaknesses. Make sure that the community understands your value. So, that's the first, Bill, is the idea of knowing your community.

The second is educate your decision-makers. We talked about this earlier. And the decision-makers go beyond your board members. It also includes your medical staff, your providers, and all of your employees. We have about 900 employees here at KSB. I consider those people a 900-person marketing team. They can take the information that we share and take that out into our community. So, the second is educating the decision-makers.

And then, the third is communicate. And that's communicating through multiple mediums. Not everyone wants to hear the information the same way, so it has to be and and not or. And then, as I mentioned earlier, that authenticity and transparency in those communications.

Host: I love those three. That's terrific. So, know your community, number one. Number two, educate your decision-makers and then communicate through multiple means, like you said. I think that's really good. And then, transparency and authenticity really goes a long way. Before we wrap up, Dr. Schreiner, final thoughts from you, anything you want to add for any rural health care leader listening to this right now that could be in a really tough situation? What would you say to that person?

Dr. David L. Schreiner: Well, my first thought, Bill, is just around the idea of thank you for what you're doing. The task that you take on when you get out of bed and driving to work every morning, you're making a huge difference in your community, and we appreciate that so much.

The other thing that has been so helpful to me is having that ability to reach out to my colleagues, to talk to people outside of our service area, to other hospital CEOs, other hospital leaders, past or present, and just ask for advice. When you were in this situation, what did you do? What was a great outcome that you led? What advice can you give me about the things that were most successful when you were going through this? We're all in this together, so let's go through it together and let's support each other.

Host: What a great message, what a great way to wrap up a wonderful interview. Dr. Schreiner, thank you again so much for your great thoughts and we are looking so forward to your keynote speaking session at SHSMD Connections 2024 in Denver. Thank you again.

Dr. David L. Schreiner: Thank you, Bill.

Host: And Dr. Schreiner is going to be a keynote speaker for this year's SHSMD Connections. Stay tuned for early bird registration for SHSMD Connections 2024 in beautiful Denver, Colorado, October 13th through the 15th. See you there. And if you found this podcast helpful, and come on, how could you not? Please share it on your social channels, and please hit the subscribe or follow button to get every episode. And to access our full podcast library for other topics of interest to you, please visit shsmd.org/podcasts. This has been a production of Doctorpodcasting. I'm Bill Klaproth. See ya!