As you may recall from one of my previous videos, or may just know already, there are different forms of communication, right? There's public communication, like public speaking. There's mass communication. There's communication in groups. But in this video, I want to focus in on communication that takes place between two people, and more specifically, two people that are in a relationship of some sort. So we're going to focus on what's called interpersonal communication. So we want to define in this video what we mean by interpersonal communication and what separates it from other kinds of communication, and even what separates it from just what we call dyadic communication, any communication between two people. So we're going to try and separate some of these things for you. So interpersonal communication in a broader sense is just communication between two people in the context of a relationship. And when we say relationship, we're talking about could be a romantic relationship, could be friendship. It could be a family relationship, but it could even just be a relationship that you have in the workplace, a non-romantic relationship, a connection that you have with coworkers that exist in the workplace. So any kind of relationship, though, communication that is between two people in the context of a relationship is defined as interpersonal communication. And that separates it from some different other types of communication, like mass communication and public communication, because it's between two people specifically, and involves a relationship, but it's also separated from what we call dyadic communication, d-y-a-d-i-c dyadic, meaning two. Not all communication that takes place between two people is necessarily interpersonal. It could be what we call impersonal. So we're going to separate a little bit here what we define as an interpersonal experience from some of those other things, including impersonal. So let's take a look at the characteristics of interpersonal communication. What's involved, if we say something is interpersonal, it needs to have these factors involved in it. So first, there's uniqueness. Interpersonal relationships are unique. They're different. They're all distinct from one another. There's a sense of uniqueness. There's not an interchangeability in an interpersonal relationship, an interpersonal context or experience. You can't just take one person out, throw somebody else in, and have it be the same. There's a uniqueness to that relationship.   You go to the self checkout line, but if you were to check out with a person, is there a massive difference? Is there a relationship that exists between you and the cashier, assuming you don't know them beforehand? No. You go to one checkout lane, it's going to be basically the same experience. Some are a little faster or a little friendlier or whatever, but it's going to be, here's your total and here's what you owe, and thanks for shopping at Walmart. Those are what we call impersonal experiences because they're not unique. There's nothing distinct or really separate about that relationship. You could have basically the same experience going through any one of those lines. So interpersonal communication involves relationships that are unique and distinct from other relationships. They also involve interdependence.   In fact, that affects every part of the pond then eventually, right? Or if you make one change to an ecosystem, then it affects everything involved in that ecosystem. In the same way, these relationships involve interdependence. When your friend comes over and they're in a really bad mood, they broke up with their girlfriend or they're at a loss for a job or whatever, and they're sad. That affects you too. You're sad for them and it impacts your emotions and what you're doing that day. Friend comes over and they broke up with their girlfriend. You might as well cancel your plans because you've got to spend some time consoling and talking to this person and things in the same way in a family relationship. If somebody in that nuclear family loses their job, it impacts everybody else in the family. There's a system there and there's an interdependence between those people. This connectedness, this interlocking system in interpersonal relationships that's not there. If something happens to a complete stranger, you might feel bad for them for a second, but it doesn't really impact your life, right? So there's not that interdependence. Interpersonal relationships involve a sense of interdependence. They also involve a degree of self-disclosure, right? When we are in a relationship with somebody, again, romantic friendship, family, whatever, there's a sense of we disclose about ourselves. We tell them about ourselves. We share things and they share things with us. When you check out at Walmart, you're probably not divulging your deepest darkest secrets, right? That would be considered inappropriate there. In interpersonal relationships, again, whether it's romantic, whether it's friendship, whether it's family, whether it's a coworker, when we're sharing things, sharing about ourselves and having those moments of self-disclosure, that's a characteristic that has to be there for it to be considered an interpersonal relationship. And finally, interpersonal relationships involve intrinsic rewards. Intrinsic rewards. Now, intrinsic rewards are if we do something because it feels good to us on the inside. There's no explicit reward, for example. If we're running this race and there's a cash prize at the end, that's an extrinsic reward. If we win, we get this money, that's an extrinsic reward. But a lot of people compete in marathons and they have no intention of winning. They don't expect to win this marathon. But man, they do it because there's some sort of intrinsic reward that's driving them, right? This is the sense of completion that they've done it, the sense of accomplishment. That's an intrinsic reward. And in the same way relationships carry, interpersonal relationships involve intrinsic rewards. We get things not extrinsic. You could have extrinsic rewards in these relationships, too. If your friend is a pool and you get to go use it every once in a while, that's an extrinsic reward. But intrinsic rewards are things like joy and loyalty and a sense of comfort with the other person, a level of comfort, the ability to self-disclose things about yourself. Those are all intrinsic rewards. They don't carry any tangible or monetary value or anything like that, but they are still critically important. We don't have those kinds of rewards outside of interpersonal relationships with just people we don't know, we don't really get those intrinsic rewards in the same way. So interpersonal relationships don't need to involve these four things. If it's not unique, if it doesn't involve interdependence and self-disclosure and intrinsic rewards, then it's not an interpersonal relationship and the guidelines and rules of interpersonal communication wouldn't necessarily apply in the same way. So when we consider interpersonal relationships, we need to remember that it involves these distinct characteristics and then involves communication between two people within a relationship. Other types of communication are a little different, so we need to understand what's involved in interpersonal communication so that we can be more effective and competent in our communication in those situations. If you have questions about anything related to interpersonal communication, including what establishes an interpersonal relationship or the characteristics of interpersonal relationships, please feel free to email me. I'd be happy to chat with you about it via email. Otherwise, I hope that you will begin to examine these relationships and how they might be demonstrating those different characteristics and how that might influence your communication so that you can become a more effective communicator.


And in Business News, the World Bank has stated that it has disbursed $31.7 billion as climate financing its 2022 fiscal year and that this is a 9% increase from the $36.6 billion it recorded in its last fiscal year. According to it, lending from climate related investments reached 36% or about $31.7 billion exceeding its new climate finance target of 35% as outlined in the 2021-2025 World Bank Group Climate Change Action Plan. It added that Nigeria got $700 million from the amount disbursed for an agro-climatic resilience in semi-arid landscapes.


Hello everybody and welcome to this session. So my name is Morgan Rishom I'm any V architect for orange and I will do the presentation with Arthur Bresen and director of product management for a cloud if I so the topic today is but VMS deployment in a PNF V and by extension some lesson learned on best practice for VNF and boring on open stack So Okay, so the agenda will first I will Give some some indication on what is VMS. I know that we are in open stack summit VMS sounds really talco and really And they so few world on VMS then we'll detail why we need an orchestration We will come back to open a V and fun tests with a functional testing in opnav focus on the VMS test case that has been fully integrated in opnav and a conclusion about Lesson learned and what will be the future for VNF testing within opnav project and more globally on open stack So first of all, what is VMS? So I don't know if you are all familiar with beautiful talco architecture so VMS means virtual IP multimedia subsystem, it's a Framework that can be defined by 3 gpp Quite a long time ago now It's an architectural framework to deliver IP multi multi major services Today, it's mainly used for voice over IP services And if you have service provider providing voice of IP services usually it's managed by VM by the IMS solution It's fully designed fully defined lots of standardization behind all the interface are fully defined So it's a very complex and rich telco architecture offering large-scale telco deployment including all the telco usual Constraints such as legal interception emergency number etc etc So as you can see, I will not detail all the box, but lots of people Rock on that they detail all the different interfaces all the different Box and the protocol everything so it's really usual stuff we do in telco Where people spend yours defining that and then the vendor they are implementing Solutions and we make lots of interoperability in order to make all these books working well together So it's still very Interesting to consider VMS because it's the core network is used for LTEs the new evolution of the network It's very well known in the telco world It's already deployed in lots of telco you have some constraints That are specific also to telco such as legal interception and adjust numbers I say usually people from IT They say oh you just have to get rid of your infrastructure and do everything from scratch But we have really big constraints that we we must take into account and and that has been precisely defined So why deploying a VMS? So because it sounds really any V in a PNV project that will detail a little bit later We started putting very basic tests such as ping between VMs But for telco making ping between VMs does not really make sense So it was decided to to find something that sounds more in a V And there was an open source cloud ready solutions on the market. So clear water solution by Meta switch It's very well known if you are used to attend Mobile World Congress on any summit Then you have lots of demo with Meta switch solution But the idea was really to be able to to to integrate it and to automatic automate totally the solution From the orchestration to the testing so this solution is already deployed by some telcos and We need also an easy solution to orchestrate it and to see how it was visible to have a VMS in a DevOps Loop on on C. Oh, it was possible And why it's an open stack because open a V even if it's not Mandatory, but today in the last version of Colorado the 37 scenarios that have been Validated are based on open stack as a cloud provider So open stack is no more an option Open stack has been adopted by most of the telco in the keynote yesterday morning So that any way was one of the key topic. So it means that my colleague from Germany is a they were on stage showing that okay, we are dealing with any way last year AT&T received Super user world this year. It was China mobile. So you can see that telco are Part of the business and VMS for them means something So that's a very brief introduction on VMS and then I will give the floor to Arthur to explain why we need a VMS, but we need also a way to orchestrate it Thank you Right, so we've seen this diagram this nice little diagram, which is very simple, right? So essentially You know systems such as an IMS it's very complex system It has a lot a lot of components which essentially, you know Come comes down to the basic or a component that we are all known and familiar with right so that you know Essentially virtual machines virtual routers. Maybe some neutral configuration Maybe some some software that we install on top of that virtual machine But essentially these are repeatable components that we use in an environment essentially, you know There's a lot of complexity into creating the right setup and the right The right deployment for a working actual environment So orchestration is a is really all about, you know taking automated processes. For example Install a router configure router install a virtual machine on with specific configuration for and prepared for a specific deployment For example, you know add EPA configuration to that virtual machine those kinds of automated processes And orchestration is both taking these automated processes and essentially a Deployment a deployment in a repeatable manner and in in a manner that That can create the right Workflow to bring up a actual working environment So essentially orchestration is all about creating these dynamic workflows based on those repeatable automated Processes so, you know, obviously, you know, we take this such as a complex example as an IMS And you know, we break it down to say several repeatable components and essentially we created the dynamic workflows to onboard and to install and then Manage these applications on runtime as well Now one of the challenges obviously, you know, we can script the whole thing We can script, you know, the automated scripts on top of that But one of the very complicated things about orchestration is making sure that you have the right context For each and every component in the environment, right? Because like if you're installing in a virtual machine The next component that needs to install on top of that virtual machine needs to know all the details from that virtual machine Now the next virtual machine, for example, we have, you know, another virtual machine that that has the router on top of that It needs to know the credentials in the IP address for the first virtual machine that we installed So we need to know and pass the Intel in the context of the whole deployment intelligently between these dynamic workflows that we produce in order to onboard such a complex environment So I'll give a short introduction into Clotify. I'll try not to steal too much time today So essentially Clotify is a, you know, an NFV orchestration platform It falls under the orchestration for service and resource orchestration Category but also is a generic VNF manager based on Tosca. It's fully open source And we also have a commercial addition to it Based on the premium package and the cool thing about it that is that it's highly pluggable I'll detail that in a bit But the main idea here is that essentially everything that you can think of and has an API and has a way to connect to it and Control it somehow programmatically. We can very easily plug Clotify into the whole loop and to to orchestrate That that specific device So as I mentioned earlier, Clotify is based on Tosca Tosca has three main parts to it. The first is the topology essentially a YAML description of the application topology Which looks something along these lines. Obviously, you know, I can have a small unit of measure. I can have a larger Composed blueprints for the more complex application to describe my whole network service And I simply, you know, use a simple DSL a simple YAML DSL to describe my topology And yeah, this is language right Tosca essentially is a description language So you can always extend it you can always introduce new node types For example, you know the language itself comes with a set of normative types That I can consume for describing my application but can always extend it Okay, so what I mean by that is that I can introduce a new node type to expose and express a new a new Component that was not, you know, was not included in the in the original Generic set of types that I can use as part of the language and then I can obviously compose My application based on these node types And now the second part and the more complex and interesting part in you know in our review is the workflows essentially a workflows workflows are Very important to be this to be the declarative right and what we mean by the declarative is that we produce this Workflows and we execute these workflows based on the topology All right, so essentially I have my application description as we have the example here And I have you know very simple application simple to know the application Obviously each of them can be a scaling unit of its own so I can scale for example the the compute node for for the database or for Whatever and then we essentially based on the life cycle Events based on the life cycle operations. Sorry for each again node type Okay based on these life cycle operations We can produce a workflow dynamically to trigger for example and install Operation for specific VNF for example just for onboarding, right? So these are the declarative workflows and obviously we also have the imperative workflows So essentially you can you have your own internal workflow in your you know For your specific VNF that you would like to express so you have the ability to create that imperative workflow as well With an access to the topology So we this is something we call the context of the of the deployment. So essentially once you Once you deploy a VNF you have a context You can always access these components using simple, you know simple Python code in order to for example pull out an AP of a database or pull out an AP of router or or you know Query the number of interfaces for a specific device. So these are the imperative workflows Now the third and third part to complete the whole picture is the policies So I can set policies to trigger specific workflows based on events that are happening in my environment So for example, I I monitor my my CPU load on my virtual router And once I recognize for example the amount of traffic the amount of the volume of the CPU the memory consumption, etc, etc I can you know a Take these metrics and describe a policy saying that once I reach a certain load I can trigger a scale event for that router, right? so that policy will simply trigger the scale workflow and Essentially part of that workflow. I would simply steer the traffic part of the traffic to my new virtual router that have just a Provision so these are the policies So just to put the whole picture together I'm I'm describing in a simple blueprint simple task a blueprint my whole application and in that blueprint I can include, you know, the resources For example, I can have scripts. I can add to have ansible components to install specific parts of the application can have chef Modules, etc, etc If I if I choose I can use an image for example, or I can choose, you know a pre-deployed Imaging glance if I if I'd like to depending on how I create the descriptor for my application So clarified essentially takes that application blueprint and Uses a set of plug-ins in order to communicate with the underlying infrastructure To onboard that application, right? So for example, if my application blueprint contains an open-stack node, obviously the open-stack plug-in would have the logics To access the open-stack API to trigger the you know The Nova command create and obviously pass it with all the needed parameters in order for it to work successfully For example, you know creating the neutral network creating all the dependent components and passing all the needed parameters for that and Then you know the really cool things we can do with that is that we can mix and match types, right? So you can use an open-stack type inside that open-stack type we can describe using a Docker type for example and inside that Docker type we can describe deploying an application, right? So we and then we can say The networking piece of that is implemented using an SDN controller, right? So we can have a description of a network that is being controlled by an SDN controller open daylight for example And then we can create this topology for this application essentially cloudify talks with the APIs In order to realize and onboard and install and manage that application. So that's a quick intro to cloudify Thanks So now I will speak a bit more specifically on open eva and fun test on all we use Clarify to integrate the water of your solution So first of all open eva, I don't know if everybody is familiar with that So basically initially the scope was to work on the integration because it's an integration on testing project Integration of the best of breeds of the open-source world in order to build a telco cloud solution To build telco cloud scenarios with lots of integration. So difference as in controller different feature So we put that together we test it and we give some confidence into the different Integration we can have so initially the vnf out of scope of that But of course if you want to stress a system you need some vnf to test it so that's The way open eva is doing so we have integration testing on new feature Project a new feature. It's one that has been shown in a keynote. So the doctor or the fault monitoring So every time we detect something that is not covered today We can initiate a project that will try to answer to a problem and the other main project are testing and integration So we can see here the different components were integrating and that are Distributed among the different project that are testing through CI and a federation of labs distributed all around the world in order to provide confidence into the different integration So the this project is under the Linux Foundation Organization lots of company are taking part to do that So what we do is we give confidence to scenario. That's what I want to say So a scenario two days up and stack plus network controller plus feature plus mode mode meets high availability or non I availability so for a functional testing for example, you have Different tests you run and then for example here you have two scenario You have the onos sfc scenario So you have the onos controller plus sfc atoms in order to have this feature and here you have a noise Dn so it means a pure neutrons with pure open stack with that feature and on hs So that's a dev stack or something similar with different installer and then you have the different test so that's what opnav is doing and Today we have different Combination of course was different installer different tests Different way to do into an automation for the installer. We have fuel from Maranti Sergio a red at to do canonical and compass from way away and for the test project We have functional performance qualification storage different test project that are dealing with specific aspect The third release has been announced on the 22nd of September and we are working on the fourth soon so My project I used to be PTL until two weeks on the functional testing project Was ready to to deal with functional testing in open a bit So does it work does it not work? We have internal test case such as V-pings as I say between different VM feature test and we have also of course reusing Massively all the upstream test suites that already exist So we are running rally rally running tempest running ODL or onos testing suites in order to give to the integration a global scoring and Confidence level For fun tests we use a docker file So you can use it even if it's not opnav any open stack based solution can use This this docker and it can be used to trigger all the different tests we have today so it includes the tooling the test scenario and The test yes a test scenario So fun test will also give an automatic reporting based on all the different results at what you show in the picture and Then you have a global scoring So now I will come back specifically to VMS and that's where open source is really cool So unfortunately this gentleman cannot be there today because he's at school I need the one responsible for for for the MS in opnav is an internship in orange It's six months at school six months around and you know he is smart on he was a bit fed up playing with Lego So he said okay, I will play it with advanced Legos and then he looks okay clear water is a cool Lego Clarify is a cool one. So he makes a match and he's the one who really Put all this stuff in motion and it's quite funny because when you say it's I know 20 or something like that And he didn't really ask for a lot of supros because the different Legos were well documented and was able to to build a complete end to an integration on automation of the test case in opnav So I mentioned the VMS solution here. That's the VMS implementation by clear water so all the interface respect the VMS Three GPP specification the implementation is a bit different and we say it's clod really for example We use a Cassandra ring database so an SQL database for for the HLR and things like that So implementation is a bit different. It's really clod ready, which is interesting and Why we choose clodify at the beginning we test several solutions But clodify was open source, of course It was one of the condition, but there are different orchestrator even if there are more since we start out But the integration with open stack was pretty clear. I'll say no need to Spend hours in in documentation documentation was was very good There was a full life cycle management already integrated in the system It was based on Tosca. We rounded that as well and the plugins There's an openness of the solution was very very nice So that's why we decided to he decided to go to to to clodify It's possible to probably you attend in several I say SDN World Congress and Any any meeting there are lots of demo with with clear water VMS and you can do it with Other orchestrator, but this one was really easy to implement and easy to integrate into the open evi from work So yeah, you can see an example of the Tosca descriptor so the blueprint you can download it if you want the description is relatively simple and Based on the restrict descriptor on the Tosca, then we will just show a step-by-step deployment of the system So in open evi we have labs So what we call farce lab farce is the name that the name of the project managing all the infrastructure So in open evi we have more than 20 lives. I think and it's automatically managed by Jenkins When the installation of the system under test of the scenario is done in one lab Then we call fun test fun test will create a docker or a corner in machine aside of the system Then he will ask weapons act to create the first resource each other the user of the tenant everything then fun test with In install clarify on a VM and it will download all the The Tosca stuff in order to be able to deploy automatically all the VMS including the different nodes or Instead of a sprued bono helix correspond to what we used to call in VMS CSCF HLR all the 3gpp basic stuff Then it run that Additionally in a fun test counter meta switch plan they develop and a set of Signaling testing so we have more than 100 signaling testing testing the different interfaces So it's purely seep here. You don't have a performance or stress test But lots of signaling with all the different scenarios or register Invite re-invite redirection of call etc So you're able to automatically send all these tests your provision automatically the database and run all the testing And it's run from the jump post so from something that is considered out of the system So it's really seen as a black box and the test as an user And when it's done it collects a result and he pushed a result to the result API that is used to give the scurrying to the scenario So at the end the results will be something like that. So here so it's a last June so you have the three step So the orchestrator time for deployments was at the time we we we need for for the plamont of Clarify then the clear water deployment and Signaling testing so can see here that the testing was not so good But it has improved a little bit and we we had the complete list of testing So some tests were useless For example, we don't have service application on top of this VMS So we were trying to to test it anyway So we improve that and in the next release we exclude this So that's what has been done by by a valentine and it has been integrated already in the end of the brahmaputra release So the release before the one From September, but it has been improved since this date and we can see that Based on this test case we learn seven things and for the next release we plan to have more vnf on boring and Practical testing of the vnf based on the same methodology that he used for the ims So the main lesson learn is the test case. It is interesting because testing just audio or Component is interesting, but for telco we need systems and we need telco grade system So we we had a VMS solution that where was telco grade and we have also An orchestrator tool that allows us to deploy it very easily So it's here in 40 minutes. You have a complete Deployment of a VMS. So if people are working in ops In telco, it's quite quick regarding what we have usually So we have access to so we learn lots of things doing this we we saw also some constraints that lead to some improvement on Some installer so they need to do some improvement And we were able to make also a functional test It's interesting to see that the work that have been done here. I've been reused massively after that by Vendor that use all the toss cascript and the methodology and the documentation that have been done for pnav As part of the training. So I know that my renties Allure Nokia on other company use it as an example So it was interesting to see that the work from the students that just play legal with technical building blocks Was back to to vendor in order to sell it to telco that create this thing, but it's quite unusual So for the future of the vending testing what we believe is that orchestration battle just begun So there are lots of orchestrator on market at the moment lots of open source solutions lots of different options What we want to do in opinion base, okay There's a slide battle, but we want to have a reality battle So what I say to people coming with okay have a new orchestrator, which is the best of the world say, okay Just integrate a test case using the same methodology and show show us that it's in CI on that We can because as it's in CI we're able to run VMS on all the installer on all the platform on get results So so we were really able to to distribute it massively into different configuration with different as in controller on see The potential problems. So what I said to them is just do exactly as we do Create a test case. So maybe not behind us. You can select other ones on for the next release in opinion They will have new vnf. So there is a project from okinawa labs to have a vrouter and they reuse clarified because it was already there And I think they find it also very simple. That will be VPC from open interface coming with juju as vnf So there will also other combinations that are possible But the idea is maybe to learn by doing and as today it's still not fully clear What I mean the interface between the orchestration? I mean it sees started doing the job, but everything is not finalized. So just do it learn by doing show what we can do We can also Mention that open avi organize every six months a plug fest when we welcome of proprietary vnf to be tested and We did that in Colorado last time. There is a plug fest beginning of December in Boston this year And for the future we'll have new open source vnf One or so of the option it will be to add new load test capability. I mentioned for the ims It was only signaling But there is a test project called yastic in open avi and we hope that in the near future We should be able to call yastic to generate traffic and to have additionally Also some stress test and some qualification with load test And that's it for us. Yeah, pretty much Thank you. Thank you. Any questions? No question. Okay, there you go Okay, we yeah, that's I think we cannot make a session without saying container in the session. I should have no no We do have a docker logo You're right. You're right. I mean we didn't try it yet because in opnv at least we are not Necessarily doing everything with open stack we were Validating scenario of integration Okay, but that's true that today all the scenario of integration are based on open stack And there is no scenario with open stack on Magnum and things like that. It's only pure open stack with Kevin It's only that It's pretty sure that we can do that also in contner We will maybe do it in the future because there will be new scenario coming and they will integrate container There is already a scenario in One scenario is dealing with LXC and LXD in opnv So we can reuse it that but the VMS have not has not been tested because you need some adaptation It has really been done in first step at least the automation script has been done to to match the default configuration but In opnv we are trying to be to address all the scenarios So we will have to adapt them to the V to to the LXC scenario And maybe later if you have a Kubernetes or anything dealing with that We will try to adapt that here and adapt with the people that are coming with the scenario But today I know I have no example in all my list of scenario of the VMS deployment in contner I I don't see any main obstacle for that But yeah, so we didn't do that. So we'll be happy to see Contribution to these repos of you know supporting containers and supporting difference Exactly Yeah Exactly. Yeah, it's essentially it's a set of applications. You need to containerize and once you containerize them you can Orchestrate them. It's that's essentially by the end there. That's a story Cool. Any further questions? So that's a actually a good question. So why claudify and not heat for example? So heat is solely focused on resources of open stack, right? This is the orchestra though the open-stack orchestration project But usually it's very important for you as a user to to first of all to be able to support Multiple VMS because essentially you want to have the ability to move your application from one VIM to another VIM if you Have your hot template you're pretty much bound to open stack and the second reason is that usually you do integration with additional technologies Right, it's not only that you want to orchestrate open-stack machines or open-stack resources You want to also for example integrate pop at chef Yeah for the test it's clear you can use it you can use chef you can use whatever you want But the guy who decided to implement it He did that with qualified because he think it was simple and he was very happy with all the life cycle Management that was not available, but that's clear that initially when metas we choose to be in opinion V when they say they start doing There's this test case. It was based on on heat simply on heat and it was It was not integrated in the CI because it was he is not finalized and when we in orange decided to We won't really this test case into the release then we Yeah, so the guy who made the implementation just select his favorite Lego and this time it was well But it works perfectly well with other orchestrator and I say juju has also charm to do it if we want and That's the battle for orchestration. I say it just began but what we can say is from our experience it was quite straight forward to do it was qualified and That's why for the new test case As I mentioned people reuse exactly the same piece of code to redo the same thing So deploys orchestrator or deploys vnf test your vnf But there are also some test case in open evis that are just doing the stuff with heat and It's working also fine. There was another one. Yep Could you speak a bit high but a lot or maybe go to the mic my understanding if you start your test case You had a container first is correct that from that container You first install a virtual machine on top of open stack with cloudify within and then within that come Within that virtual machine running an open stack you start by reconfiguring these the same open stack Deployment correct. Yeah, we have we have a tenant so from the fact that from the docker We just initiate the creation of the resource on open stack creating a VM on this VM We install clarify then we ask codify to consume the task file from this task Clarify call open stack again to create a different VM within the tenant and organize all the network and associate Deployment from clear water. So that's I think that's what you say, right? And would you say that this is a best approach of configuring the open stack from within the open stack or would you prefer? In operation that you have it outside So usually right so usually, you know you you see the diagram essentially you have the orchestrator talking to the open Stack right but the orchestrator needs to run somewhere as well So usually the best practices or this is what usually folks are doing that they're simply using the same Infrastructure but in a different tenant so usually they have the admin tenant with they you know with the with the management software and orchestration software And then the workload itself runs on a separate tenant or maybe separate region separate availability zone depending on the configuration of the of the specific open stack setup and depending you know on how the organization is running their own Their own environment Thank you. Any more questions? All right guys. Thank you very much


This study found that listening to non-rubble music had a significant calming effect on hospitalized children, resulting in lower levels of anxiety and decreased vital signs. This article was authored by Asher Falsadat-Hakim, Sedershima Hosseini-Kaldoski, Ashraf Tashakori, and others.


Okay, so I will call our meeting back into order for August 14th and we are going to hear from Rutland next. And what we'll do is Mr. McCracken will swear in the Rutland witnesses and then Miss Fox. I'll turn it to you for you and your team to introduce yourselves and provide an opening statement to the board. And before you get started, thank you all for being here and Miss Fox. Congratulations on your new position. So happy to hear from you. Thank you. Good afternoon, Miss Fox and the Rutland team. If you could let me let us know who is going to be presenting and answering questions. And if you wouldn't mind also spelling your name when you introduce yourself, that would be very helpful. My name is Elizabeth Cahill Elizabeth traditional spelling and then Cahill K Y H I L L. Good afternoon, Jonathan Reynolds, Vice President clinical operations here J O N A T H A N R E Y N O L DS and Judy Fox president and CEO and it's Judy with an I J U D I F O X. Mark Foley chair of the board of directors. It's M A R K F O L E Y Kelly Watson chief nursing officer and it's K E L L Y W A T S O N. Thank you all very much. I feel raise your right hand I'll swear you in. Do you solemnly swear that the evidence you shall give relative to the cause no under consideration shall be the whole truth and nothing but the truth so help you God. I do. Great. Thanks very much and I will turn it over to you. So thank you. I'd like to start by thanking chair foster and all the members of the Green Mountain care board for the opportunity for us to support the Rutland community by allowing us to highlight information that we feel is informative and relevant and important to the decision that you the board has before them. I'd also like to thank director Lindbergh who has been a consistent and transparent partner to Rutland regional as we've moved through all aspects of this budget. We have found director Lindbergh's questions to be both inquisitive and helpful and we'd like to acknowledge her in her work in providing a benchmarking tool that is consistent among hospitals. I won't introduce the team again. We have introduced ourselves. You'll hear from each one of us. In addition to the team that will provide testimony. We are also joined by hospital leaders by physicians and board members who are all here in sport in support of our community and our budget. But I first want to ask our board chair Mark fully junior to provide a few opening comments. Thank you Judy. Good afternoon chair foster and members of the Green Mountain care board. So much has happened since you visited Rutland regional last December. Most significantly as Judy noted the board named her as permanent CEO in June. Judy's exceptional leadership and organizational credibility has made an immediate impact on Rutland regional. I want to thank you for the opportunity to provide comments on behalf of Rutland regional. I've had the privilege and honor to serve on the hospital's board of directors for nearly eight years spending the last 18 months as board chair. As a native of Rutland and a fourth generation business owner. This community in this state are especially important to me and my family. Rutland is where I grew up. It's where I raised my family developed my business and where I focus much of my volunteer service. Rutland is a special place with much to be proud of and like many rural communities. It faces ongoing challenges. Rutland is an aging community. We are impacted by increased substance misuse and addiction. We struggle with increased mental health issues and like communities across the state we struggle with housing and workforce shortages. More and more our community relies on Rutland regional medical center. Our local health care providers and human service agencies for support in a variety of central services. As a longtime resident of this community. I want to ensure that Rutland is a vibrant and strong one with a thriving economy and healthy population who can experience all that the region has to offer. This requires a strong community hospital. As one of the region's largest employers the hospital plays a significant role in the strength of our local economy. It is a relied upon leader and partner in the community collaborating for the greater good. Supporting economic development and revitalization efforts and helping to further the mission of local nonprofit organizations aimed at improving the health and wellness of our Rutland County region. For more than 25 years the hospital has led a community health needs assessment identifying health improvement priorities and supporting projects that address the health needs of residents in the Rutland region. The hospital has worked closely with community partners, coalitions and organizations to address the identified health priority areas outlined in the 2021 health assessment including housing, mental health, childcare and parenting and supporting an aging community. In support of those health needs of our community, Rutland Regionals James T. Bowes Health Trust has been awarding and managing grants in the Rutland region since 1997. Since its inception the Bowes Trust has awarded more than 4 million to programs aimed at improving the health status of residents throughout our region. Because of these efforts and more, Rutland region is a trusted and relied upon partner in our community. 2022 was a difficult year and while we needed to raise rates we have also taken a diligent approach to lowering costs. The hospital has done considerable and effective work over the past number of months to reduce costs, address culture, workforce and safety issues. We are focused on keeping high quality care in our community by investing in physicians, nurses, staff and equipment as support community needs with timely access to care right here in our region. As a board, we realize that our workforce is our most important resource. Our community relies on our dedicated healthcare leaders, providers and staff in so many ways. Attracting and retaining experienced providers and staff to live and work in our region is critical to our ability to provide high quality healthcare to our community. It's also important to understand that Rutland Regionals is just one of the many health core organizations in our community. We value our strong collaboration with our partners and we are committed to our continued work with primary care, mental health, home health and other Vermont hospitals to provide care in the right place by the right provider and at the right time. Thank you for the opportunity to be here this afternoon. At this time I'd like to invite Judy Fox to share some of the details of our 2024 budget. Judy. So like other hospitals in Vermont, all of whom we've heard from Rutland Regional has faced significant challenges in trying to strike the right balance and providing high quality access to care while addressing our cost structure and acknowledging concerns of affordability. As Mark had said, 2022 was a very difficult year. We lost $12 million from operations and when you layer on our investment losses that amasses $41 million of loss. As a result, we were in breach of debt covenants risking a bank call of $43 million of debt. We were able to agree on a covenant suspension that but unfortunately the process was costly and it also required that we increase our liquidity position to be increased until we could demonstrate ongoing compliance. And so that was difficult. The breach also weakened our ability and capacity to consider additional debt while we are also at the same time trying to come out of COVID and support our mission and vision. While our loss was significant in many ways, we need you to know it was also deliberate. We have faced and continue to face staffing shortages both within nursing and direct care providers and also with our own physicians. To date, we have 176 open positions and we're also recruiting for 12 full time positions. Regardless, we made the decision not to limit access to care. Instead, our RMC remained committed to reinforcing our workforce through use of temporary staff and our locum physicians. This was costly. In 2022, it drove additional costs of nearly $24 million. In 2023, we expect about $21 million of additional cost. And in 2024, while we've made some impact, it's still $18 million. Elizabeth Cuyhill will share how our RMC maintains our strategy to deliver value based care in our own community, despite these staffing shortages. Thanks, Judy. Good afternoon. Again, I'm Elizabeth Cuyhill and I'm the vice president of medical group operations at Rutland Regional Medical Center. So at Rutland, we take the strategy to ensure access to value based care seriously as it requires that we care for 60,000 residents in our service area. It's an honor to take care of our community and to provide the right care at the right time. Last year, we cared for just over 6,500 inpatients in our facility, more than 100,000 patients in our clinics, and we provided nearly 300,000 outpatient testing, imaging and ancillary services. We treated 31,000 patients in our emergency department. This strategy involves a carefully crafted multi-pronged approach that enables us to assess the immediate and long-term needs of our patients and to put a system in place that allows us to have our practitioners be the best that they can be. It's not easy because we continue to struggle with increased complex care needs of our patients, changes in payment systems and a workforce that seems to be shrinking and harder to hire. The metric of lag time provides a high-level comparison for patient appointments, and then we have patient satisfaction surveys that ask questions like, did you get the appointment as soon as you thought you needed it? And that gives us some insight into kind of a high-level comparison for patient appointments as well as our patient's perception. However, even combined, they don't give the full picture of is this the right care at the right time? Prior to and in between those visits, there's a significant amount of care that's occurring. The goal is to create touch points for the patient so that when their scheduled visits occur, the patient has gotten the right care at the right time. The practitioner is performing to the top of their license and the costs are controlled. However, even with all those touch points happening and that we're putting in place, we still need to have available provider appointments. That just has to happen. So with our greatest workforce challenge being provider at recruitment and retention, we struggle to provide enough of those appointments. Physician vacancies have a direct correlation with our access. It's true and with our patient satisfaction. Recruitment has been a challenge due to the decline in available physicians wanting to come in coming out of their training, willing to work in rural areas that have that don't have that plethora of sub-specialties as well as minimal call requirements in rural communities that they're on call more. Cardiology, OBGYN, infectious disease, ICU and ENT are areas that we have struggled with recruitment due to those reasons. We have incorporated advanced practice providers. We've increased call stipends contracted with third party telehealth services. We've utilized locum agencies. Those have all been the things we've been doing to make sure our patients still have the right care at the right time. Daily, our physicians, advanced practice providers, nurses and staff work with our patients to help them navigate through the system. We get the care in a timely manner, but it does take a lot of work and touch points. This continues to be a challenge at the system level and we're going to continue to work hard to find solutions and take care of our community. Thank you for your time and I'll turn it back to Judy. So acknowledging the challenging position that our RMC faced, we appreciate the Green Mountain Care Board's support of our 2023 budget request. And we acknowledge that this request is far more significant than any other year. While our 2023 rates bolstered our financial position by providing necessary funding for inflationary costs, we knew as a leadership team that our financial stability would require actions greater than rates. And so this spring, the senior leadership team in alignment with our board initiated a cost reduction program that resulted in savings of $5.6 million and we eliminated 45 positions. Again, our goal was not to impact access to care, but rather to focus on administrative overhead and efficiencies in patient care. Our reduction plan was an appropriate balance between clinical services and administrative overhead. The impact of the reduction drove our cost per adjusted discharge down by more than $275 a discharge. And we'll support improvement in our RMC's cost as we compare ourselves to other benchmarks as those benchmarks are updated. Together, the rate increase and our disciplined approach to cost containment provided a foundation to develop our 24 budget. To stabilize our financial position, our RMC used realistic assumptions that support utilization trends, inflationary factors and cash flow needs. And it is important to note that most, if not all of these assumptions were supported by Green Mountain Care Board guidelines. The inflationary impacts facing healthcare have been profound. Jonathan Reynolds will provide information as to the inflationary impacts in our 24 budget, as well as to discuss the impact of diminished revenue capture opportunities within our 340B program. Great JR. Thanks Judy. I'm Jonathan Reynolds again. Supply chain disruption coupled with high demand for supplies have driven cost up. Increased pharmaceutical costs, especially with many new drugs coming to market, demand inflationary funding that is excessive. The inflationary impact of pharmacy alone in our budget is driving more than $1.3 million. RMC mitigates inflationary costs for both supplies and pharmacy medications by participating with Vizient in the Northeast Purchasing Coalition to secure discounts related to group purchasing programs. Through NPC alone, RMC leverages cost savings and excess of $1.1 million each year. In addition to significant inflationary pressures, RMC has been confronted with sharp declines in our 340B revenue. Our 2024 340B revenue budget has been reduced by $3.5 million, a result of many drug manufacturers imposing contract pharmacy restrictions. 26 drug manufacturers have imposed restrictions thus far. As of June, we estimated our annual loss to be $6 million while our budget only projected a loss of $3.5 million, proving to be an assumption that is already negatively impacting our performance. It's vital for our state legislators, state health departments, and hospital leaders to recognize that declines in 340B program will significantly impact all Vermont hospitals. Based on our 2023 projected operating performance, Vermont hospitals across the state would have an aggregate loss from operations of more than $5.6 million if not for the 340B program. This is in stark contrast to an operating gain with the 340B program intact of $59 million. 340B serves to subsidize underfunding in state and federal health care programs, and without 340B, Vermont hospitals will be at risk for financial sustainability. To continue our cost efficiency efforts and to offset these negative impacts to financial performance, RMC has put in place a controlled hiring process that requires the review of every position, whether budgeted or not, to determine the need for funding. The process is not only a tool to manage costs, but also to stabilize our workforce. Regardless, RMC continues to be challenged with staffing shortages, most notably in our nursing and direct patient care services like diagnostic imaging. I'll now transfer it over to Kelly Watson, our chief nursing officer, who will provide an overview of these workforce challenges. Thank you, Jonathan. And thank you members of the Green Mountain Care Board for your time this afternoon. As Mark Foley mentioned in his opening remarks, our workforce is our most important resource. Judy shared that we have over 170 positions open or org-wide, with over 100 being nursing-related positions. Efforts on recruitment and retention to address critical staffing shortages are top priorities, as is lowering costs associated with managing those critical shortages. As Jonathan mentioned, ongoing assessments of resources, resource needs are reviewed weekly, where we utilize benchmarking and productivity data to validate any staffing request. After we validate the need, we move quickly to fill vacancies to ensure access to care remains intact. Recruitment efforts have included grow our own programs, tuition reimbursement, sign-on bonuses, flexible working schedules, and developing meaningful partnerships with local academic institutions. Several of our employees, myself included, serve as faculty and clinical facilitators with Vermont State University's Vermont Tech and Castleton Nursing Programs. This allows opportunities to engage with students while also providing exposure to our organization. In collaboration with the Vermont AHEC, we engage with high school students interested in healthcare careers, which is another workforce pipeline we believe is worthy of our investment. While workforce recruitment is a top priority, equally as important is retention. Retention efforts include enhancing our recognition programs to ensure employees feel valued and appreciated for their dedication and hard work. Creating a safe work environment is another key element of retaining employees. We have heavily invested in creating a safer work environment by implementing new violence prevention tools, a new training program, increased security surveillance, and enhanced access controlled practices. We recently hired 30 new graduate nurses to join our team, and their success is critical to our success. We are in the process of reassessing our new grad residency program to ensure its value. This includes adding a mentorship component and utilizing new grad feedback to make program adjustments as needed. Another retention tactics, other retention tactics include listening to our employees, working collaboratively with our nursing union, utilizing exit interview data to improve our performance, and developing leadership training programs for our current and future leaders. Investing in our workforce, implementing innovative staffing models to maximize resources, and partnering with academic institutions are key components of both recruitment and retention. Critical staffing shortages have pushed us to be more innovative than ever before to ensure effective utilization of resources while we have continued to provide high quality care to the communities we serve. At this time, I will return the presentation to Judy Fox. So to conclude our introductory comments, I'd like to talk about our rate increase. So, as you know, our RMC is seeking an increase of 5.6%. We understand that the impact of increases in our community and we strive to limit the increase as much as we can. We have been responsible in both our request and have complied with the 8.6% trend factor that was established by the board's guidelines. It is important to note, however, that while our increase is 5.6%, commercial payers are only paying about half of that. The difference relates to contractual agreements or changes and payment rules that impact our reimbursement structure. We'd be happy to discuss this further, but ask that this would be considered privileged information and we would be looking to talk with you about this outside of the public setting. We'd also like to convey our approach in supporting individuals who do not have insurance or who face high deductible plans. Our RMC's financial assistance program allows full funding up to 300% of the federal poverty level and partial funding up to 500% of the federal poverty level. The result is that we budgeted included in our 2024 budget $7.3 million, which is equivalent to 40% of our entire self-pay reserve, which would include bad debt. Our RMC agrees that the current system is not sustainable and that it is our shared responsibility to find collaborative, creative, and innovative ways to change the way health care is delivered and paid for. That said, we caution any decisions that attempt to impact the cost of care without a full understanding of the factors that drive our current challenges, merely taking funding out of the system without changing care delivery, investing in supportive community programs that address mental health and substance misuse, or acknowledging the inequity in the current payment systems will not serve anyone well. Particularly Vermonters, who need a strong health system to be in place to care for them. Thank you. All right, thank you. Those were substantive opening remarks. I think I took good notes. You presupposed some of the questions I was going to be asking today. So, you know, thank you. It's almost like you've been through this before. All right. So we're bringing up the two here and the board, I think it's important to note that this is one of two submissions that did fulfill the benchmark, which again is net patient revenue growth from fiscal year 22 actuals to the 24 budget of 8.6% or less, which was established in the fiscal year 23 guidance. And then that they met that very ambitious target. I think that's just something really important to keep in mind as we walk through this. So, they are the only PPS hospital that was able to fulfill that target. We heard from two others that were quite close. And they also have note the negative find in the operating expense field so that is largely what is helping make this budget comply with those requirements. We spoke at length about how you're approaching labor and how you were thoughtful about the reduction in workforce. I'm curious, it sounds like, you know, best laid plans and all that. How confident are you that operations will be smooth at this level of staffing or do you have any concerns about having to replace some of these positions. Well, from the nursing perspective, we're, we're being very mindful of staffing to our census to make sure that we're not just assuming that we, we need every single resource at every single moment. So this is working really closely with our leaders throughout various levels of nursing to ensure that we are monitoring that. But we do have, as Jonathan and I both mentioned, we are looking at our staffing needs every single week and really trying to be mindful to see, you know, we absolutely have to replace this person to keep this service intact. And so that's, that's an ongoing, I don't even want to say weekly, it's a daily assessment to ensure that we're utilizing our resources. It's the best we can. Yeah, and it sounds like part of your assessment in addressing those resources has to do with productivity. How does that fit into the equation about hiring versus addressing it through productivity measures. So we have a new benchmarking process that we subscribe to, we submit data on a pay period basis, and we then are allowed to get information back that tracks our productivity against like peers and cohorts. We use that information. That's part of our controlled hiring. And that helps to inform those decisions. As Kelly and Jonathan both said, controlled hiring is a process that, you know, we meet every week discussions honestly happen every day. Sounds like a lot of information that you keep up to date, but that makes a lot of sense. Any other questions from the board related to labor expenses specifically. Just one quick follow up. I'm just wondering what percentile you benchmark against when you're thinking about that productivity, the new data that you have. Sure. So our goal is to get to 50, the 50th percentile. There are some departments that are already there.  So this goal is really needs to be addressed and managed at the department level with the long term goal of getting everybody close to that 50th percentile. Thank you. Miss Fox, what's the name of that tool? It's called premier. And how long has Rutland been using it? We have been using the productivity component of this system for about, I'm going to say three or four months. We use that in earnest when we began our cost reduction program in the spring of the year. It has two modules, a productivity module and a benchmarking module. Honestly, we're just beginning the benchmarking module. I can't sit here and tell you that we are proficient and mature in that. But certainly that is our goal as we move forward. Thank you. All right. Advocate, any labor related questions? Yeah, thanks, Sam push healthcare advocate. I just want to commend Rutland and you, Judy and your team for the coming in below the guidance and implementing the cost reduction plan. I think that obviously takes courage, commitment and a lot of careful planning. So I was wondering if you could just at a high level speak to how you arrived at that decision rather than asking for an increase in commercial charge and or NPR. And if what kind of obstacles you had to overcome and doing that. Sure. So I will speak on behalf of Rutland Regional Medical Center. Every hospital in the state has a different set of challenges and you'll hear from them. But we were really coming off from COVID. We had provided a number of services during COVID that we had to make decisions on as to whether those were important to move forward. And so was really looking at how we were redefining our hospital and our services post COVID. It starts with at the top. Our board is fully engaged and is working with us on strategic strategic plans. And then it moves throughout our senior leadership team and our leadership on the ground. And so it takes it takes everyone the courage. We came off from a year where we had to ask for excessive rate increases. We knew that that was very difficult for our community. Having said that there is high demand for our services. And so we were trying to strike that balance between access and cost. Thank you. Thank you very much. As far as utilization. Seeing that it was up quite high in fiscal year 22. I know that that's not a terribly representative year for utilization most places. So just curious how you in a nutshell tackled the puzzle of utilization in your budget. Yeah, sure. So speaking of 22, which serves as the base for this trend, our patients came back quick. And we were very busy as soon as restrictions were lifted. I think we were in the OR the next day. So we were ready to move forward and have really worked with our community and building kind of a safe environment for them to come back in. Having said that there's an enormous amount of delayed care. And as our patients were coming back online, that has certainly been very evident, whether it's in our ED or in our inpatient units or in our clinics. If you look at our ED utilization, which is your bottom graph there, 17% of our patients are admitted from our ED that's a little higher than the state average. The state average is around 13%. We are seeing patients who are our sicker come through our emergency emergency room. On average, we see about 85 patients a day, but that varies that can go anywhere from 60 to 130. And so the transition in those in those patients really are challenging for our care teams. And as far as 23 and 24, we're staying the course. What you see for utilization is really what we're treating in patients today for patients with the exception of a couple of areas. We use our wait times and our lag information to make decisions. And in that case, we saw that high end imaging, particularly CT and MR had very long lag times, not good for the patient, not good for our providers caring for that patient. So we've opened up hours, lengthened the hours in the day. The equipment is the equipment, but then also opened up weekend hours. We also have an expansion project underway for infusion where we have seen a great demand in our community for infusion services, which is a good segue to pharmaceutical expenses. I know oncology is a huge structure for a lot of organizations. Just curious how you're kind of grappling with that coupled with the 340 be challenges. Yeah, of course. So we're able to benchmark the medications that we use, especially in our cancer center in our non cancer infusion settings. Visiting our GPO provides a drug pricing forecast that comes out twice a year that we can run our drug mix through. And you'll see that as a result of that, that's where the projected inflation of 4% came to be. I know that the benchmark nationwide was 2.3%, but the 4% is a highly specific number to Rutland Regional and hence the rationale for that being in there. So it is based on true data and true utilization numbers. You know, in terms of the volume, we, as Judy mentioned, we're just seeing increased requirements for medications that need to be infused. And for Vermonters, it's all about access in rural areas. We support these patients that come to us and receive this care as it's a bit different than other metro areas where there are more in home services. So that is really a difference in this setting here. Great. So I think, again, given that these just, I'm sorry, these factors and their sources were very well documented and the submission came in within the benchmark. I don't have a ton of questions and the rest of the content areas. So I wonder if we want to cover anymore from the board or the advocate before we go through the other cost exhibits. I have one question. Sorry, Sarah. And I could hold this for later. I'm not sure when is best to ask it, but also I'll ask it now in the narrative on page seven. Judy, you talked about the Medicaid fixed payment change. And I'm wondering if you have any information about what's driving that. Are you talking about the $600,000 budgeted loss? Sure. Yes. Yes. So that number is quite volatile. And so that is the difference between what we get and fixed payments from one care and what we call shadow payments. What we would have received had we not been in a one care fixed payment program. And at the time we were putting our budget together for the months of March, April and May, we were behind by about $250,000. And so this kind of eeks and flows in terms of patient demand. But as we see the increase in costs, we don't expect that this is going to get much better. And so that is really a result of looking at our fixed payment against both our adjudicated claims and those claims that we consider lag and waiting to be processed. Thank you. One question I'd like to pose. First of all, I just want to say thank you so much for the very well written concise but detailed budget submission. It was incredibly helpful. And one thing I really wanted to highlight in this, which has been I think a really great addition to the discussion on custodial care patients is your analysis on on page 16, which is really very helpful to understand the problems, the challenges and the financial impact that you're experiencing from these various challenges with discharges. And so I thought this was a really helpful and clear description of that problem. So thank you. My question relates to this, which is actually to have you, what are other challenges that you have found with throughput of in patients challenges length of stay other than custodial patients. And what are the other challenges that you've been able to identify and understand the impact of them and any mitigation strategies. Sure. So before I answer that question, I do want to give a shout out to Springfield hospital. So with our custodial patients. Our care team has gotten together with Springfield hospitals care team looking at ways in which we can provide care for these patients. A better location and with a better reimbursement structure. We're very early in on this process of only transferred one patient, but it's really important as we think about how Vermont hospitals work together. And in this particular case, these custodial patients are really important. And that happens to be our Medicare patients actually awaiting a waiting placement. So there's that piece. I would tell you that when we look at our utilization, our utilization is less other than the custodial. It's less about who's getting in and more about how long they're staying. And so if you look at our utilization statistics over the last four years, in total, we had less than the 150 days denied for in patients because of a utilization denial. Where we are seeing what we call avoidable days is where a patient has come to us for acute need, but we can't get them out of the system. And that's not just custodial. It's altogether different. So we could be holding a psychiatric patient in our ED and the state has provided some reimbursement for some of those patients, but not all. We have same day surgeries where we have a surgery that is predicted to be outpatient. But for whatever reason, the needs of that patient, they have to stay. We call it same day surgery extent. They may spend the night with us unplanned. We have observation patients. On average, we have about three observation patients a day. Most of these observation patients are medical patients. Most of them relate to cardiac and rule outs. But those are all areas in which we have what I would consider patients in inpatient beds that may not be fully acute. I don't know if that's helpful or not. I think so. I guess I guess I was trying to get at is, are there patients that you have an inpatient bed? Do you have a process of trying to identify those that could be managed more expeditiously? And if you found from that process, anything that you could find benefit to intervening on? Yeah, great question. So last month, we had two patients undergo surgical procedures. Those patients, one was a general surgery patient. Another was an orthopedic patient. Both of those patients did very, very well. We discharged them the same day. We then received a denial from the insurance company. In this case, it was Medicare because those procedures are only paid on an inpatient basis. So although we did everything right, we didn't receive any reimbursement. So my point in sharing this with you is it's complicated.  We have to lean on our physician leaders to help us make some of those really skilled decisions. The other pieces with Medicare Advantage, we have patients who we hold in our facility longer than we need to because they're in a Medicare Advantage plan. And we have to wait for a prior authorization to get them to their next stage of care. That can hold up care two to three days depending on the situation. Thank you. That's an area we've been hearing about frequently this last two weeks. Judy mentioned a quick follow up question to this whole conversation around, you know, uncompensated care. We heard from another hospital that there's a new long term care facility opening up. There's going to be increased capacity. My understanding is 60 new beds. Will this help in your mind in the Rutland area and how might it impact your assumptions about length of stay and utilization. So I hope so. I hope it helps. The largest impediment of custodial patients and moving patients on our lack of bed for either a payment source or for a perceived behavioral issue. And so depending on what this long term care facility criteria is, we would really be looking to partner with them. Having said that, not sure when this facility is supposed to come online. I'm not sure that it will be too impactful in the near future. More of a long term planning tool. Okay, thank you. Any other board questions or advocate questions? Hi, so this is Charles Becker. I'm a staff attorney with the health care advocates office. I suppose I should have waited for the board to make sure that there were no more board questions before I jumped in. Were there no more? Okay. All right. So it was unclear to me to where my question might fit in. So I it relates to 340 B. So I thought I'd jump in now. So thank you. You noted earlier that there are 340 B revenue declines stemming from manufacturer restrictions on contract pharmacies and I read that in your narrative and that got me to thinking that, well, you also have an in house pharmacy. And and that led me to be to wonder even more. So what is RMC doing to help uninsured and underinsured patients with high pharmacy costs because you serve a community with a lot of lower income folks. And I imagine a lot of people get great care from one of your specialist physicians, but then they get prescribed the medication they can't afford and so they don't adhere to the treatment. You know, looking over your website, it doesn't look like our RMC offers any financial assistance to its in house pharmacy. And so my question is, has our RMC ever considered passing through some of its 340 B savings to uninsured or underinsured patients by implementing a prescription drug financial assistance program through its in house pharmacy. I will say indirectly, not directly. If you look at our financial assistance program, we provide full financial assistance up to 300% of our federal poverty level. We also provide a tiered financial assistance up to 500% of the federal poverty level, which I I believe is the highest in the state. And so we use our financial assistance program to work with those patients that are most vulnerable. If a patient is receiving pharmaceuticals as an outpatient, those those pharmaceuticals would be part of our financial assistance program and they would be eligible for reimbursement or assistance. Thank you for that. And maybe following these hearings, if you would be open to it. I mean, I was reviewing your websites just just today and it is not at all clear. In fact, it says that pharmacy costs are excluded from your financial assistance policy. So, so maybe we could work together to make that a little bit more clear to folks. Absolutely. Thank you. I'm going to jump off, Charlie, just a kind of more broad question. From reading your community health needs assessment and just being a little bit familiar with the work of the bow's health trust, it's pretty clear that Robland is committed to health equity. And I was wondering how your team evaluates making progress towards specific, you know, goals that you set or specific race equity metrics over time. So the first step is measuring and putting together a measurement system that allows us to understand where baseline is and where we're headed. We have a team in place that is working through that process. That team is in working in partnership with our diversity equity inclusion committee to support the work of the committee. The bow's health trust took a fairly inflexible stance, if you will, to begin our process that we would not entertain the funding of any community project if they could not validate and confirm for us their stance in DEI and how their funding, our funding would impact those vulnerable communities. Thank you. Sarah, I think the whole HCA team is keying in here. So I've got one more. Actually, I'm the last member of the HCA team to ask a question. Good afternoon, Mike Fisher, health care advocate. I wanted to spend a moment talking with you all about bad debt and free care and I'll start with a recognition of, you know, your hospital over time over the last number of years has, I think, been in the lead or close to it. And with regard to that relationship between bad debt and free care. And yes, Judy, I think you're right. You also lead in the generosity of the 500%. For partial payment. So I wanted to recognize that, you know, 2022 was a bit worse.  I wanted to spend a moment asking to understand a little bit of these numbers. I have to admit, board and public, I have a little concern that my focus on the relationship between what's counted as free care and what's counted as bad debt might have some some challenges with the math in how people in different hospitals calculate the value of free care and bad debt. So I wanted to ask when a claim becomes recognized as free care. I think that the math is, you know, amount generally billed or or an average commercial rate. Do I have that right. So if you are looking at our 990, that would be a correct statement. If you're looking at internal financial statements, it's a bit different. It's the full charge. It's the full charge for financial statements. Okay, that's interesting. A similar question. How is is bad debt valued? How's the claim become recognized in in bad debt? So there, there is a waiting process. There's 100 a day window where we will try to engage with our patients to not not ask for full payment, but to at least get to an agreement of a payment plan. After the 120 days we're unable to to make that reach to to the patient, then we will begin to move through a bad debt process, which then does provide additional notification. Right. I'm sorry. My question maybe wasn't clear. I'm saying, after you've moved through that whole process and the claim, you know, you delivered some care and the person isn't paying for whatever reason. And it's being counted as bad debt. How does it gets valued?  It's it's it's charges. It's charges. Okay. Are there any scenarios where an individual claim can get counted in multiple categories only give it, for instance, you know that you have a commercial payer who pays part of charges. And so there's an amount between what was contracted with the payer and charges. Would it be reasonable to count part of that claim as bad debt? So that's where I think you're referring to likely or possibly high deductible plans where there is an adjudication process of payment processing with the insurer. The residual value would then be transferred to self pay. At self pay balance, we would look to collect from the individual patient. At that point, the value is, is the deductible or the copay? Yeah, that makes perfect sense in that scenario. I'm sort of, I think I was asking in a different scenario where sort of the difference between the commercial, the agreed, the negotiated payment and charges could be counted. I've heard stories of hospitals counting that difference as bad debt. And I was asking whether you could envision that or whether that's a practice that Rutland would use. And so that's getting into pricing transparency. And our commitment to follow those rules and regulations with pricing transparency, where we do use the metric generally payments generally accepted. Do you know if I also have been hearing that there's some changes in the, you know, counting standards update that is going to require hospitals or maybe it already does require hospitals to count bad debt as more akin to what you would expect to collect. Yeah, so that's the revenue recognition standard that generally accepted accounting principles has adopted. That that took months to implement here. Probably not great for a dialogue here, but it would certainly entertain a conversation with you if that would be helpful. I think that's the right answer. That's the that's the right next step. I am interested in sort of what's next or how has things changed recently and what's next in terms of how these things are calculated and I would be thank you for this dialogue here. I wanted to have some of it here and I would welcome an opportunity to do follow up later. Thank you. And I'll tell you on that, you know, I think making sure we're as congruent as possible and clear about definitions in our own financial data collection that that's what the board's all about we want to get that cleaned up and predictable so well taken. So, I know we have a hard stop at three and I just want to make sure that the board feels like we're using our time to the best of what we want to do so I don't know if you want me to go through these cost exhibits or if you wanted to have any other conversation before we do that. Are you asking the board Sarah. Yep. Yep. Is there anything else you wanted to tackle before we go through these tools. I just want to make sure we have time. Okay. I'm okay with proceeding. Okay. Great. So, again, curious person data is an information can sometimes be harder to get to as we discussed earlier so from the relative standing of Rutland on the cost reports we see that you are pretty large for a midsize rural hospital. Between the 75th and over the 75th percentile, but, you know, not quite an outlier. And one thing that I think is always important to note is that, you know, this not the hugest hospital in the world, but in terms of the relationship between the hospital and the ED, your, your ED is pretty big compared to your hospital compared to what we might typically see. So I think that's something to also keep in mind. So, you and CVMC have very similar acuity ratings. It's hard to get you at 1.46 are just kind of wondering if you also are feeling that the coding intensity might be not as accurate as you like from your experience. No, I think I would say our coding teams do a really good job. We actually have audits and their work is reviewed on an annual basis. Okay, cool. All right, that's helpful. And again, you and CVMC are very close at around 20% of that ratio. Again, that would be line five salaries compared to the full gamut of clinical salaries. I have a feeling that your corporate structure might be distorting this indicator. I wonder if you have anything to say about that. This is 2022 data. It's already old. And the, the cost reduction that we put in play for this spring certainly will be impactful there. I would also just based on your previous comment, Sarah, that this is one look at administrative costs. If you look at our, our financial statements, you're going to get it all together. And so really understanding the source of data is really important. We did put that in our narrative to try to highlight that as a concern as we move forward. Having said that our corporate structure that we have all services within the hospital. I think we have one FTE that we float out to our parent company. But other than that, all services and all FTEs are reported within the hospital structure. Yeah. Okay. Thank you. Very helpful. So fiscal year 22 is not very representative in terms of current position and any means. So I don't know if you want to say anything about the cash available for operations indicator. Yes. So talking about our corporate structure, I will tell you that early in the year from a cash perspective, it was, it was really difficult. We actually transferred cash from our parent into the hospital so that we didn't have to immediately realize any losses within our investments. And so that's a little different for us. And that that was probably important to share with you. Yeah. Thank you. And then really tough to see that operating result 22 is just really, really hard here and I think some hospitals hit harder than others. But that stands out. And then here. So again, this is per Medicare discharge adjusted by the Medicare CMI. So seeing you're at the kind of top end of that whisker. So about one and a half times above the Sunday. Anyway, what do you want to say? So that was a driving force behind our cost reduction plan this spring. We have numerous benchmarks that we look at and knew that we had an opportunity that we needed to begin to to move forward with. I just appreciate your, your directness and candor. I appreciate that. As far as cost coverage goes, I'm going to go to the right section this time and I'll see Rutland here. So, in terms of a cost standpoint, you know, pretty close to peer hospitals, a little bit higher. And seeing that cost coverage is very similar to Brattle boroughs among the commercial population, but a higher average payment those assumes that you're probably doing more intensive services. And then I see that the inpatient kind of commercial, you know, Medicare allowable cost coverage has been pretty flat and just barely covering costs. Whereas we again see kind of the deterioration for Medicare and kind of a slow downwards slope on both sectors for Medicaid. So just curious, especially with the Medicare Advantage penetration, how you're kind of tackling some of these case mix challenges. There are so Medicare Advantage just to speak a moment on that we've had about a 25% increase in that utilization Medicare Advantage is about 16% of our total revenue. However, our denials for the organization Medicare Advantage drives 40% of our denials. And so that's just an important piece to note. In this commentary, in terms of costs, again, I will see these change just a bit as we think about the cost reduction. And there's a there's an awful lot to say within cost coverage and with commercials and I have highlighted that in some of our testimony. But probably I consider that to be some privileged information that I like the opportunity to talk with the board if if you so desire to drill down on that any further. Understood. I was just validating you can see both the cost and reimbursement for commercial in 2017 and how far that's really come down. Not just for yourself, but I just think that's always important to keep in mind. And last but certainly not least is a random data, you show up in the exact same spot in both distributions so just probably whatever is halfway between 50% and 75% half of that is where you are on both distributions so kind of in the 50% of the data so not really stand out in that way. So I think that was all I had to cover on that those exhibits I don't know if there are any questions, comments from board members of the advocate sounds like there might be some other conversation that we might have in an executive session but leave that up to you all. This is Tom Walsh. I just wanted to take a moment to acknowledge the hard work that you did based upon the cost data and you've mentioned several times that in the face of data that showed higher administration expenses per discharge. You've taken aggressive action and managed to stay within guidance. I think that's to be commended. So I just wanted to be sure to say that. Thank you very much. Thank you. Anything else? I share Tom's feelings. Well done. Strong submission and thank you for making the hard decisions you needed to make for your community. Any other board or advocate questions for Rutland at this time? Are we going to go into executive session or are you trying to get all of the public in questions out first? I don't know if the board has interest in pursuing any of those questions. I think that's up to you all and I also think it would be fine to do a public comment before we entertain that. So if any members of the public have a comment, why don't you use the raise your hand function? Sometimes midwestern questions aren't translated so it looks like no public comment. So does the board have interest in any further inquiry in an executive session? We're going to let them off the hook, huh? Yeah, I think that's a testament to a straightforward complete submission within guidance. So we genuinely appreciate the hard work you're doing and thank you for your time.  Thank you. Thank you. We appreciate your time today. Oh, I'm sorry. Any closing comment before we send you on your way? I mean, I'll be the chance. Yeah, I guess I would just offer that it's really important we want you to know our operating margin has been really thoughtful. It is we're not trying to get 3% or it really was derived out of needs for this organization both within just liquidity and debt repayment as well as capital needs. We have some pent up demands for capital. If you look at our four year plan that is associated again data matters. It's really important and we have an aging plant. And so we're really positioning ourselves to address some of those needs for our community. Some of those needs are linked to safety issues. Some of them are linked to increasing access based on some of those wait times. So I just really want you to understand that we were really thoughtful in that approach and that honestly is what drove a lot of the work in the budget. Thank you. Yeah. Thank you. Right. We're good. All right. Well, thank you. Thank you. Thank you. Have a good day. Bye. It was well. So, sir, I think. Are you all set? We're all set. Yeah, we'll be back. But Wednesday is a state holiday, so we won't see y'all till Friday.


Phytoestrogen Kempferol exhibits anti-cancer effects, but the action mechanisms are still unclear. The study found it suppressed the proliferation, promote apoptosis, and limit the tumor-forming, scratch-healing, invasion, and migration capacities of EC cells. No significant toxicity of the drug was found in humans at non-cytotoxic concentrations. This article was authored by Guanyin Wang, Li Xiong Yi, Jian Songlin, and others.


Welcome to the appendicular skeleton, the arms, legs, and their girdles. The skeleton is divided into two major portions, the axial skeleton and the appendicular skeleton. The axial skeleton consists of the bones of the skull, the vertebral column, and the ribcage. The appendicular skeleton consists of the bones of the upper and lower limbs and the bony girdles that support them on the body trunk. This learning object examines the appendicular skeleton. The pectoral girdle is composed of two clavicles and two scapulae, one set for each arm. The clavicle, or collarbone, is easy to recognize because of its S shape. The scapula, or shoulder blade, is flat and irregular. The glenoid fossa, or cavity, forms the arm socket with the head of the humerus. All shoulder movements include the sternoclavicular joint, the only body joint attaching the girdle to the trunk, which is formed by the medial end of the clavicle and the sternum. The upper arm is called the humerus. The upper extremity of the humerus consists of the bone's large rounded head. Also located on the humerus are the coronoid and olocron fossa, which accommodate the forearm bones during movement at the elbow. The two lower arm bones are the lateral-positioned radius and medial-positioned ulna. The hand contains 27 bones including 8 carpal bones and 5 metacarpal bones. Four fingers each have three phalanges, but the thumb only has two phalanges. Hip bones that comprise the pelvic girdle are much larger than the bones in the shoulder girdle in order to help the body bear weight. The hip bones are also called the oscoxy. Each coxa is made up of the ilium, ischium, and pubis. The upper leg consists of one bone. The femur is the longest and strongest bone in your body. The lower leg has two bones, the medial, bigger, and stronger tibia, and the lateral, deeper, and inferior fibula. The seven weight-bearing tarsals or ankle bones are much larger and stronger than the wrist or carpal bones. The largest tarsal bone is the calcaneus or heel bone. Five metatarsals form the ball of the foot. The foot has a total of 26 bones including three phalanges for each toe, except for the big toe which has two. The foot also contains built-in longitudinal and transverse arches for weight support. Congratulations! You have completed this learning activity.