Leading the Parade: Generating buy-in and support

Podcast Transcript

Brian Bolwell, MD: Beyond Leadership, a Cleveland Clinic Podcast at the intersection of leadership and everything else. In this podcast, we will commingle with extraordinary thinkers and explore the impact of their ideas and experiences on leadership and management.

Hello everyone. I am your host, Dr. Brian Bolwell, and today I'm thrilled to be joined by Dr. Joanne Conroy, Dartmouth Health's CEO and President. Welcome to Beyond Leadership, Joanne.

Joanne Conroy, MD: Thank you, Brian. Happy to participate.

Brian Bolwell, MD: Thanks so much for your time. Can you tell our listeners a little bit about your career journey? I think you started as an anesthesiologist in South Carolina and here you are, the CEO of Dartmouth Health. So how did all that evolve?

Joanne Conroy, MD: You're right; I did start my career at the Medical University of South Carolina. After graduating from Dartmouth, I took a couple of years off, which wasn't very common back then after college. Now, gap years, you're expected to take them. I ended up going to medical school in South Carolina. I have to say back then, it was $800 a semester. I appreciate the increase in debt that the medical students have today because fortunately I'm not burdened with that. Although I did borrow $15,000 for my father who charged me 11% interest. [Brian laughs.] We forget that in 1979, 1980, we were in a little bit of a recession back then. So, news flash for everybody on the recession we may go through now.

I started medical school there and actually stayed and completed my residency there and then stayed on faculty there. I was there for 22 years. It was a great experience. It was probably a time where there were not a lot of women in medical school down there. Fewer than 10% of their class were women, and not a lot of women on the faculty either. So, it was an opportunity. I think I was the first woman everything there pretty much.

[Brian laughs.]

After 22 years, I decided to go. Now, a lot of people would say, that's crazy because people love Charleston, South Carolina. And I have to say the institution there has just grown in leaps and bounds over the last 20 years. However, I was really involved in the gritty work of balancing the budget after the Balanced Budget Act. Most people that have been in healthcare for a while, remember in 1998, after the BBA, about 50% of the academic medical centers in the country were in the red. And then we had the Balance Budget Reconciliation Act a couple of years later. Most of us had a pretty big gap to fill. Ours was 77 million.

I was kind of on the sharp end of the stick as the clinical lead because I was VPMA of the hospital and I was senior associate dean for the college as well as being chair of anesthesia, and we made a lot of tough decisions. And sometimes you realize that it's important to go after filling roles like that. So, I went and took a job at Atlantic Health in Northern New Jersey. I have to say that it was a really great experience. They, and still are, an incredibly well-run health system. Something that in academic medicine I felt was lacking back then. We just didn't have great business processes. We forget in the 90s, when you had cost-based reimbursement, they paid you a percentage of your charges, it was easy to be fat and sloppy. [Joanne laughs.] We started to get a lot more deliberate about where we put our resources and became a lot more businesslike in healthcare because we had to. We wouldn't be able to survive.

I stayed at Atlantic for eight years and had just a great experience and was being considered for the CEO of the health system but decided to do kind of a weird sidestep. I'd been really intrigued by Michael Porter's book. I think it was called Reinventing Healthcare. I decided to go to Washington, and I took a job at the Association of American Medical Colleges as their chief healthcare officer. It was a great opportunity for me to not only kind of watch policy being made and realize the role of stakeholder groups like that and shaping policy, but also, I got to meet CEOs from all the academic medical centers across the country and look under the hood of their organizations and understand the challenges that they were facing.

So, there couldn't have been a better opportunity for me to go to school on what it meant to be an academic medical center CEO. There weren't a lot of physicians that were CEOs at that time. There were some. I remember Peter Slavin had been in his role, maybe, I don't know, four or five years. He was on our council of teaching hospitals. But the vast majority were actually leaders that had come up through the hospital administrative career route.

However, after six years, Washington was great, but I wasn't a DC-lifer, and I knew I was going to go back into operations. So, I took a job at the Lahey Clinic as they were trying to kind of form a new system. It was not unfamiliar to me because when I went to Atlantic Health in Northern New Jersey, they were two years into forming a system. It's tough. It's tough when you start to bring different organizations together. How do you balance the appetite for growth with the need for really rigorous expense control?

I left there because somebody reached out to me from what was then Dartmouth-Hitchcock Health, which was a health system based in Hanover, New Hampshire, where I went to undergraduate school. They asked me if I'd be interested in applying for the position of CEO and president, and I did. It was actually a very fast process. I think they reached out to me in February, and I was interviewed in March or April, and they made me an offer in June. I never thought I would return to the Upper Valley. We laugh that most Dartmouth students spend four years trying to get out of here, and the next 40 trying to get back.

It's been a really great experience. I was a full scholarship student at Dartmouth. My dad was disabled since I was 10 and I always wondered how I was going to repay that debt. You kind of feel a debt to the community, and this was the perfect way to do that. So, that's my career journey in a nutshell.

Brian Bolwell, MD: Well, that's fascinating, and thank you for sharing. So, some reflections on all the steps. So back at the University of South Carolina, you said you did your training there and then you were on staff in anesthesia, but you also made a decision, or you must have gotten opportunities to do more administrative stuff then, because you're Associate Dean of the Medical School. Ultimately, you said you were involved in a lot of challenging budgetary situations because you had administrative leadership roles. How did all that happen? How did you get interested in the first place?

Joanne Conroy, MD: Yeah. When I started my training there, I just thought I was going to practice anesthesia.

Brian Bolwell, MD: Right.

Joanne Conroy, MD: For the rest of my career. There was a defining point. The department had a new chair. I'm not sure we always select chairs of departments with the right skill sets. He was really a well-regarded researcher and educator, but we discovered about eight months into his tenure he wasn't very good at the financial aspect of running the department. The department was a quarter of a million dollars in the red. We had a faculty practice plan. The business manager showed up at my office on a Saturday in tears because she said we couldn't make payroll. Now the faculty practice backstopped us for a little while, but they basically said fix it.

And then I actually was able to appreciate the hierarchical byzantine structure in academic medicine. As I went to talk to the head of the practice plan, he says, "Yeah, you guys really have a problem. You have to fix it." But then I went to the dean. The dean wouldn't meet with me, but the senior associate Dean met with me, and he said, "The dean will never undermine the chair. So, you're just going to have to figure it out yourself." [Joanne laughs.] I actually, I met with the chair, and I said, "Listen, we have a big problem here." The faculty members are going to be incredibly upset because when you touch somebody's livelihood, meaning you touch their paycheck, they get very emotional about it, and I appreciate that. We made a decision about how to step through this without having all this chaos, mayhem, and anger emerge.

I hired somebody that actually came into the department and interviewed people, and kind of set the stage for the fact that if we were going to survive in the future, we were going to have to behave and organize ourselves differently. When we actually sat in the meeting and I revealed all the finances, there was a lot of anger. I have to say the chairman... I said, "Don't say anything. To get in a fight about this, it's not productive. We just got to fix it." He was good. Although I think he turned five shades of red, but he did not say anything in the corner as everybody was just super angry.

I said basically we're heading downhill and, in a car, and we're kind of hit a brick wall unless we actually turn left or right. The decision is up to us. They all came together, and they took 30% pay cuts. Some people left the department. But, within about a year and a half, we were back with healthy reserves and able to move forward on the departmental plans.

I think my ability, although I didn't appreciate this until I was older, I think my ability to both pull off a turnaround as well as negotiate the university politics at the same time, must have impressed somebody because I kept getting tapped for other responsibilities. I went to a program called ELAM, which is actually very popular now. It was in the class of 1998. The Dean said, "When you come back from the program, I want you to be my senior associate dean. And I want you to reorganize the funds flow in the dean's office." I did that in the midst of all the Balanced Budget Act activity, but it was actually a good platform to start to think about how we use our resources in the medical school. So, it was a lot of on-the-job training, a lot of asking good questions and not pretending you knew everything. It was probably the best type of experience you can get.

Now, I have a lot of people that ask me how I got started, and I remind them that it is a level of personal and professional risk you have to take in order to get into these roles. If you stay in your physician role, you can practice for your entire career, but once you step into administrative roles, somebody may ask you to leave. They may ask you to leave the institution, and you have to accept that. So, with the responsibility also comes some risk. I think that's the first question that physician leaders have to ask themselves is do they have the stomach for that?

Brian Bolwell, MD: So, for our listeners, there's about 28 pearls that you just heard from Joanne but let me mention a few. It sounds like you figured out how your organization worked when you were in this challenging situation with your anesthesia department budgetarily, and I think that's an underestimated skill. I spent some time at Wharton Business School a few weeks ago, and one of the books that was suggested is something called The Art of Woo. That's basically how to successfully negotiate and how to manage stuff. One of the things that they discuss is the importance of knowing your organization's social network, which is basically who really knows how to get things done, who knows how to navigate, and how can you be an expert at that.

That's what it sounded like you did is that you became an expert at your local social networking infrastructure to allow you to know who to talk to get things done, to figure out what was doable and what wasn't doable. And that's a skill that, while I think it can be honed, I don't think everybody possesses. Would you agree?

Joanne Conroy, MD: I'd agree. There were some interesting lessons learned immediately. I think the first one is that being right is not enough. We had to redesign the practice plan. I think I spent two weeks just poring over the best way to approach a practice plan methodology for the department. And when I sat with the senior leaders of the department and presented it, I felt like I'd been beaten across the back with a two by four. [Joanne laughs.] They had not been a part of developing it. So, it was didn't matter if it was the best practice plan in the world, it was not going to be successful without them being a part of it.

Very early on, I learned about buy-in. I learned about bringing people onto your team. I learned about good enough, perfect is the enemy of the good sometimes, and how do you allow everybody that got to win and participate. So those were some early lessons that had stood me in good stead.

Brian Bolwell, MD: You also brought up how very commonly in academic medicine, we choose leaders based on their research production, and that clearly is a distinct skill set that isn't the same as leading people and leading organizations. I think that's something that we still struggle with in academic medicine. How do you approach search committees these days?

Joanne Conroy, MD: When we do a search, we try to be pretty specific about the skill set we need and make sure that the search committee asks a lot of questions about why we're looking for that type of individual. In some departments, it may be more academic. In other departments, it may be more business focused. I'd have to say that as we go through the search process, however, a candidate who is outstanding but is not as strong as we'd like them to be in the specific skill set, the second step is making sure they surround themselves with people that are strong in that skill set.

So, I would say our anesthesia chair was really focused on research and education, but the search committee probably should have given him a real finance person to run the department, to be a regulator on the expenditures that basically got us into this situation that we found ourselves in a year and a half after we started.

The success of the search process doesn't end with the signed offer. It actually probably ends about two years later when the person is completely launched in the organization.

Brian Bolwell, MD: You also talked about ELAM, which I'm sure not all of our listeners know about it. It's a leadership training exercise for women, I believe. Tell us a little bit about how that might have opened your eyes or what some initial learnings were or just how all that came about.

Joanne Conroy, MD: ELAM is Executive Leadership in Academic Medicine. I believe they maybe brought their first class in in 1996. I was there at a very unique time. There were really a small number of people in our class, I think fewer than 25. It was hosted then at the Women's College of Pennsylvania. The whole AHERF thing was going on where Allegheny was creating this large health network in Pennsylvania. Not only did I actually learn a lot from my colleagues that came from all over the country, and they were at the same level that I was in organizations, but we also had a front-row seat to what was going on with AHERF.

When we met with the administrators of that Allegheny Health network in the beginning of the program, and then they came back at the end of the program and had a panel, I appreciated just the difficulty that those leaders were struggling with in a health system that was actually falling apart and actually went into bankruptcy. That was like a front-row seat what can happen if you don't make great decisions. It was an incredible real-life example for many of us. I would say that we send people from Geisel School of Medicine and Dartmouth-Hitchcock. We share clinical faculty. We send people frequently to ELAM. It's a great venue for people that really want a career in academic medicine.

I'd have to say, though, that there are limits to just thinking about academic medicine for somebody who's taken a path like I've taken. Although, we talk about the fundamentals of financial management of a medical school, when you start thinking about a hospital or a health system, it actually becomes a lot more complicated than just funding research and education, which I don't want to minimize that, it's really important to understand how you support those, but that is only part of the revenue stream that keeps hospitals and health systems afloat.

Brian Bolwell, MD: So, along those lines, one of the things that many hospital organizations are doing now is in fact creating systems and trying to create an economy of scale, looking at ways to grow. You mentioned earlier when you were at Lahey and elsewhere that these things are much easier said than done. There's cultural differences. There's motivational potentially differences. What's your view on system-ness in general? How does it work? How does it execute ideally? And when things don't work, what are the most common reasons why?

Joanne Conroy, MD: It's interesting that there's actually very little written in the literature about the life cycle of health systems, when they work and when they don't work. I've looked at the literature. One of these days, I'll write something about it. I think there are a couple of different models. All of your listeners have probably seen that continuum between kind of loose integration, which is really more of a holding company model versus an operating company model, which is at the other end of the spectrum.

Most organizations kind of huddle in the middle, that there are things that are standardized across the system and centralized and things that really are under local control. Here at Dartmouth Health, we call that things that we're tight on and things that we're loose on. I would say that there are challenges when you bring organizations together. You want to integrate best practices from the organizations that are cultural issues.

When we look back at the late 90s, when a lot of health systems were coming together, many came together, built big corporate infrastructures, and two years later had to actually do a series of corporate cost cutting because the systems were actually not big enough to support the corporate costs. And that's why people many times are looking for scale.

You may say, "Well, why do you need corporate infrastructure?" Here at Dartmouth Health, I'd have to say that our corporate infrastructure around shared services, which includes supply chain, pharmacy, imaging, lab, facilities, actually has been incredibly helpful, includes security. We can have standardized policies across the entire health system, and we see the benefit of that. Our best thinking, especially around COVID, we could apply something that we learned at one site to another site very quickly. So, the speed to execution across the health system is really helpful.

But there are things that you can't really manage from a central site. I would say much of that is human resources, how, engagement of your staff, some employee experience and patient experience issues, are really just local. We have hospitals that have 25 beds, and we have hospitals that have over 400 beds. So, we run the gamut of facilities and environments, and we have to remember that they're all a little bit different and all have their different culture. There is tremendous benefit, though in standardizing the things that make us more efficient, make us safer and really leverage the strength of our commitment to our communities.

Brian Bolwell, MD: Say more about commitment to communities, please. One of the things that's somewhat unique to the United States of America is how communities expect their local healthcare organizations to support the communities. Some areas of the country may be a little more so than others. How do you approach that as a CEO in terms of your immediate community, as well as potentially to a broader geographic area?

Joanne Conroy, MD: We are the largest private employer in the state of New Hampshire, and when you combine all of our sites, deliver more care to citizens in New Hampshire. We're kind of neck and neck with UVM for delivering care in Vermont. People forget that we're actually on the border of New Hampshire and Vermont. About 40% of the patients, at least at the academic medical center, actually are citizens of Vermont.

Our new brand uses a thoughtful, really articulation of our role in the communities. It says, "Woven into the fabric of our communities." We're the most rural academic medical center in the country. Mayo is the second most rural, but we have fewer than 170,000 people within a 30-mile radius of the academic medical center. I think Mayo probably has 220 or 240,000 people. So, we are very rural. That means that we are embedded in the community. You have no anonymity up here, [Brian laughs.], which is a good thing. But you know what? We solve world problems in aisle three of the local supermarket called the Co-Op. It is a very kind of unique place to both practice and to lead.

But you are right, the community, especially during COVID, they looked to us when everything was shutting down, we were opening up. They looked to us for the source of truth about the early part of the pandemic when we really didn't know a lot about how it was going to impact both our region and the country. Also, when the vaccines came out, we were pretty successful in having all of our employees agree to be vaccinated because it would help the communities. Both help the employees themselves and keep them safe but set an example for the community. We were the first hospital in the state to mandate vaccination for our employees. Everybody else kind of lined up afterwards, but you become a leader in your state.

I would say that leading locally and leading regionally is an important part of being an academic medical center. Leading nationally, there are things that we can contribute to the national conversation because of the unique nature of who we are and where we are. Where we are; 20% of people receive care from rural health systems in the country. And there are some unique aspects of that care, especially when we're talking about telehealth, we're talking about access to care, we're talking about equities. Our inequity is rural poverty. We're not very diverse in terms of race in New Hampshire, but we sure have a lot of rural poverty. And that has a lot of obstacles for people.

I would say another thing that's very unique is we have a partnership with the Geisel School of Medicine, which is underneath the Dartmouth College. They are our medical school partner, and we are their clinical partner. Together, Duane Compton, the Dean, who's a PhD dean, and he's awesome, he and I actually share the Dartmouth Institute, which has been well regarded as kind of a driver of health policy across the country. What's fascinating is their new leader, Amber Barnato, is starting to consider whether or not they really want to use the Dartmouth Atlas algorithms to look at health equity and look at health equity across the country and kind of approaching all of our normal data sets with a little bit different lens.

I think it's going to change how people think about how we deliver care in the country. Not only the areas of overuse, but probably the areas of under-use that are underrepresented in our current thinking within the Dartmouth Atlas.

Brian Bolwell, MD: Joanne, you're very interested in health policy. You just mentioned the Dartmouth Atlas, and you spent several years with the American Association of Medical Colleges. Why don't you explain to us what that is? Secondly, how do you see medical policy evolving in the next decade? How is it going to play out? Right now, we seem to be somewhat paralyzed in Washington, DC, to make meaningful change. How do you see ways forward from a policy perspective?

Joanne Conroy, MD: When I was at the AAMC, I actually spent some time looking at the HHS Federal Health and Human Services strategic plans. Regardless of the party of the administration and office, those plans actually are very similar. Administration after administration, they focus on delivering high value, high quality, and trying to integrate innovation in order to change our health system. They all talk about that. I would say there may be a little bit of coloring on the fringes, but most leaders of HHS have not varied from that, which tells you that it's really kind of a bipartisan approach.

There are a number of stakeholder groups in Washington that serve really important purposes. The AAMC is the American Association of Medical Colleges, and they are focused on medical school education essentially. They do spend a lot of time on graduate medical education, but a lot of their focus is educating medical students and supporting medical schools across the country.

Then there's the American Hospital Association, I'm fortunate enough to sit on the board of that now, which actually represents the 5,000 hospitals, which are part of the largest health systems across the country. They work very closely to really advance policy that will actually allow not only the organizations to continue to fulfill their mission but also to deliver greater value to the public.

It's easier said than done, because whenever you try to change a care delivery model, if your revenue model doesn't keep up with your care delivery model, it's hard to do one without the other. And frankly, we've had a hard time doing that. CMMI and CMS have done some great projects, demonstration projects. And when I was at the AAMC, we were a facilitator convener for bundle payments for care improvement, which was really the first time that a government said, let's try to save money together and we'll share it with you.

I remember working with NYU when they were working on joint replacements. They selected those two knee and hip joint replacements as their DRGs. It was really fascinating to see how quickly they shifted their delivery model when they received all the data from CMS. That is both the facilitator, but it can often be the obstacle to how we actually affect change. Most leaders would say that they want more data from Medicare and Medicaid, and we want more data from the commercial payers. So, we can almost in real-time see how we're doing in delivering care and adjust our delivery systems so we can kind of make that transition.

I think a lot of people have written their PhDs on that S-curve [Joanne laughs] between fee-for-service and value-driven care. I think a lot of us think we haven't made a lot of progress, but when you think back to where we were really 15 years ago, we've made actually a lot of progress in understanding how we can deliver better care.

Brian Bolwell, MD: Well, I think that's probably true, and I think that's an excellent perspective.

Earlier, you talked about buy-in for decisions. To execute something, you need to make sure you have stakeholder buy-in as you're trying to go from point A to point B in managing change. How, in fact, as you reflect on your leadership, do you lead? Do you engage people? Do you build relationships? How do you create trust?

Joanne Conroy, MD: I have this visual of somebody leading a parade and they turn around and they realize that nobody's behind them. That is really important as a leader to make sure you are not in that position.

I'd have to say I have a couple of leadership behaviors. Number one, I spend a lot of time checking in with my team. Sometimes, when you're in a leadership role, people are not going to tell you that they disagree with you. First of all, I try to create an environment where people can say that is really a stupid idea, Joanne. But some of those behaviors are hard to break. I spend a lot of time actually checking in with a team. I do have a team coach that works with our team. She's been working with them for five years. Sometimes they'll tell her things that they won't necessarily tell me. In a very confidential way, she'll say you need to attend to this emerging theme coming from your team. Really important to pay attention to that.

The second thing is to appreciate that again, it's good enough. Just because you think your idea is great, you need to allow other people to participate and hammering that idea into a shape that's successful. They may have a different perspective that is just as important as yours. I learned at some point not to have individual ownership of an issue, but make sure that the entire group owns it.

I do have four leadership tenants though, that I think are really important. Number one, it's being authentic. It's just making sure that you're not manipulating or managing people, but you're authentically telling them how you feel about things, and that you're encouraging them to be authentic with you as well.

Another one is integrity. Delivering on what you promise that you're going to do. I'm great at deadlines. I meet all my deadlines. I encourage people that if they can't meet them, they need to let people know why and when they're going to be able to meet them.

The third thing is being 100% responsible for where you are. We're all struggling with a miserable first quarter of the pandemic of 2022. Don't spend a lot of time blaming everybody else. There have been things we couldn't control and there are things we could control, and that's why we are where we are. We need to own it and be 100% responsible. I also use that in terms of your career choices with a lot of people that I mentor. Don't blame it on anybody else. We all make decisions.

And finally, being committed to something that's bigger than yourself. I have to say, my team, that's probably one of their strongest characteristics is they are totally committed to delivering incredibly high quality, really authentic care to the patients that we care for across New Hampshire and Vermont. And you can tell when they talk about the tough decisions they make. My CFO, before he talks about finances, will talk about our mission almost every single time. Especially when he has to talk about something tough, he wants to remind people about why we're here. That is incredibly important to ground people on our commitment to something that's just bigger than our own careers or our own financial benefits.

Those are four tenants that I think have stood me in good stead for years.

Brian Bolwell, MD: Well, I think they're great. I think that they're also a great way to build trust. They're a great way to go forward. They're a great way to practice leadership at any level.

During COVID, it was interesting. I found that authenticity was incredibly important to share everything, good and bad. When I think that, especially people in healthcare who were in the trenches at that time, in a way it was somewhat of a bonding experience. I'm really appreciative of that.

But the other thing you raised, which I think is a wonderful concept is that of a team coach, because creating psychological safety is obviously so important for a leader but having a team coach to make sure that you are fully aware of actually what the group is thinking both collectively and individually is I think a brilliant idea. How long have you been doing that?

Joanne Conroy, MD: I have been doing that for over 10 years.

Brian Bolwell, MD: Wow.

Joanne Conroy, MD: It's actually matured. Sometimes when you first start these, they think that it's the CEO's coach, and you have to remind people quickly it's actually the team coach. They get to know every single member of the senior team and have a separate relationship with them. Some of the team use them to coach through their own leadership challenges in their own areas. So, it's a benefit not only to me, but for their own leadership development, that some of them spend quite a bit of time on the phone with our team coach, which is a good thing.

Brian Bolwell, MD: In your third tenant about 100% responsible for things and owning it, I actually find that to be one of the most common challenges that some academic leaders have is that they tend to, at least some of them, deflect and blame other people, or don't take responsibility or blame the situation or the circumstances. But you're absolutely right. If you're in one of these roles, it's on you. It's just that simple. And as you said earlier, if you don't like the risk associated with that, then you're probably in the wrong role.

Joanne Conroy, MD: Yeah, that's a great summary. I think a great lesson for a lot of physician leaders that want to make that jump, it's being able to manage that personal and professional risk, and it's owning your decisions wherever you are.

Brian Bolwell, MD: Joanne, I wish we had another hour because you keep bringing up really cool points, which I think are wonderful. I'll let you give our listeners any closing thoughts about your leadership, your leadership philosophy, women in leadership. You mentioned 2022. It's very, very hard for almost every healthcare system right now. Nobody's having a good year. Everybody's dealing with a workforce challenge. And just that would lead to another 45 minutes of conversation. But anyway, I'll let you pick. What are your closing thoughts for our listeners?

Joanne Conroy, MD: I would say that regardless of the challenges that we're facing as an industry and as we're facing as individual health systems, we will get through this. Healthcare is too important. And the access and the innovation that we are currently investing in is critical to shaping what the healthcare system of the future looks like. It's going to be ugly. It's going to be like crawling across glass for the next year, probably, but we will emerge from this. We'll be stronger.

The best thing that leaders can do is continue to talk to other leaders, share ideas. We're all in this together as a healthcare network across the country. I find both support as well as a lot of innovative ways of looking at things from my peers across the country. So, I would say don't crawl up into a fetal position. Get out there and talk to your colleagues and figure out what everybody else is doing across the country in order to survive and thrive.

Brian Bolwell, MD: Joanne, thank you so much. This has been a brilliant podcast. I know our listeners are going to really, really, really welcome it and be highly engaged.

For all of you listeners, thanks for joining us. I hope you enjoyed today's conversation and look forward to having you join us again on future podcasts of Beyond Leadership. Have a good day.

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