Alexandra Peters on avoiding failure in healthcare hygiene (Switzerland)

Intro  0:00  

You are listening to the hygiene and infection prevention network. We are dedicated to sharing clinical expertise and hand hygiene resources with healthcare communities worldwide.

Dr. Marco Bo Hansen  0:15  

Hello out there. I am Dr. Marco Bo Hansen, and I'm the medical director at sani nudge. I'm very excited to welcome a special guest to today's podcast. Alexandra Peters is part of the University Hospitals of Geneva and the World Health Organisation collaborating centre. And she's lead for research and program development for clean hospitals.

Alexandra is passionate about infection prevention, security, human behaviour, and teaching. Alexandra, we are so excited to have you on this podcast. So welcome. 

Alexandra Peters  0:50  

Thank you so much for having me; I’m excited to be here, 

Dr. Marco Bo Hansen  0:53  

You are highly accomplished in your career path. Perhaps you can share some highlights from your career that you are proud of. 

Alexandra Peters  1:22  

I think I'm probably most proud of just being able to say that I work with the team that I work with currently and getting to have a lot of freedom to sort of exploring projects that I care about and write about things that I care about. I guess broadly; I’m proud of having been tenacious because that's a big part of things. And then just trying to sort of see how everything fits together and applying what I've learned over the years to what I'm doing now. 

Dr. Marco Bo Hansen  1:35  

Can you perhaps explain a bit of the team you're working with and how you're working? 

Alexandra Peters  1:40  

Yeah, so I’m mainly working at the University Hospitals of Geneva in Professor Didier Pittet‘s team. And we're also the collaborating Centre for patient safety. And so he's the reason why people use alcohol-based hand rub in hospitals. So he sort of started the whole initiative and then started working with the who. And it's become this huge worldwide movement with the most, the vast majority of countries signing pledges and ministries of health committing to this and being able to be a part of that in some small way has been gratifying and getting to travel and seeing how, you know how much health care workers are interested in how much they want to learn about the subject, and how much work is, you know, left to be done? Because when I, when I initially got there...my backgrounds in more in health security and like, bioterrorism stuff, and I could have at the time, I don't know about now, but at the time, I could have told you which terrorists would like which sort of pathogen and why. And so I went from what I thought was the sexiest subject to like, how to wash your hands, right? Or how to, you know, rub your hands right, or when to rub them or when to wash them, or you know that cleaning a toilet is science. And so at first, I thought, well, you know, I want to do this Ph.D., I want to be here in Geneva working on this. And you know, it doesn't matter if I'm doing terrorism or hand hygiene, but like, the more that I got into it, the more that I got passionate about it and fascinated by it. And so, still now, and I just really sort of glad that I ended up where I did. 

Dr. Marco Bo Hansen  3:24  

Yeah, it sounds awesome. And as an infection preventionist myself, I am so happy that you have made this great research and all the work you're doing within this space. That's truly amazing. But how have you managed to make hygiene more sexy? 

Alexandra Peters  3:43  

I think it's a question of getting institutions to understand how self-evident everything is and getting them to understand why, why we need to be having this conversation, and why it's exciting and why it's groundbreaking. I mean, when I started in environmental hygiene, I didn't know anything about environmental hygiene, you know, there was this public-private partnership that was starting to be built up. Professor Pittet said, Hey, I might have a project for you because I've always been sort of interested in environmental stuff. And then so I started working on this one sort of Clean Hospital that was still just starting to come together. And yeah, it just got really exciting because I realized that the field of environmental hygiene is sort of like the Wild West right now. Like there are limited amounts of data on everything. There's so much work to do. There are so many different types of products of there's of technologies of ways of doing things and the way that that you know; culture has a lot to do with it and the role of cleaning staff or environmental service staff within the health care institutions and how they're

I have seen and sort of integrated into different institutions. And so it's just it's, it's super interesting, and there's just so much work to be done, and nobody's done it all yet. So being able to be at the forefront of something wasn't something that I expected to be able to do. And so, I think it's sexy.

Dr. Marco Bo Hansen  5:23  

I think so, too, and you are in a hand hygiene blue ocean, you can say.

So, I want to speak of culture, and I want to talk about the importance of culture in managing infection Prevention and epidemics and pandemics in general. So, one thing that fascinates me about your bio is that you have lived and worked across many cultures; you are a polyglot in terms of language. So what are some of the differences that you have noticed in how infection prevention conversations are managed across cultures? I mean, in sort of a caveat is so in infection prevention, 

Alexandra Peters  6:03  

I've only ever worked here in infection prevention when I was in the US or elsewhere, I wasn't working on that specifically, but I have searched. So I guess most of my experiences that come from just, you know, when I travel or work closely with people from different cultures on infection prevention, I think I see major differences. Just what's interesting to me is seeing how different countries react differently, to the COVID pandemic, and seeing how, you know, some are a lot more transparent than others, some give their people a lot more responsibility, some don't some, you know, so there's all these different, you know. You have some populations that just really sort of latch on to fake news and to sort of this whole anti-vaxxer thing, and, and then other populations that are just, you know, thrilled, as soon as they can get vaccinated are much more likely to wear masks, or so I think a lot of that is, is culturally based. And I think culture impacts how people will behave and how they learn, and which types of elements are the most important to them. And I know, for example, we tend to associate a lot of behaviour with resource levels and education levels. But it's not only that, when we're trying to figure out why people behave the way they do, for example, here, you know, nurses were over, and I'm not talking just about Switzerland, but it was just in Europe; generally, nurses are overworked, during the pandemic, they're exhausted, you know, and the people are clapping for them at the same time that some European hospitals are cutting budgets for, you know, for staff. And, you know, that's enough for some healthcare workers to become really sort of defeatist. And what I, you know, what I have seen is that there's sometimes this attitude, well, you know, we're probably just going to get COVID no matter what. And so it's, you know, and it's difficult to tell them, no, you're not, when, at the beginning of the pandemic, when we didn't have enough information, we didn't know enough about spread, we didn't know a lot of things. We're asking these people to take these risks and to go in there. And, you know, and then, of course, at some point there, it's not abnormal, and it doesn't, you know, speak badly of them for them to just say, Well, you know, I'm probably going to catch it anyway, there's, I'm going to mess up at some point anyway. And what was very interesting is that we did see spread among healthcare workers just from them weren't getting it from patients as much as they were passing it to each other in the break room, or carpooling in the morning, or things like that. And so there's, you know, perception of the risk issue. And, yeah, so, culture may be socially constructed, but that doesn't make its effect any less real. And it needs to be taken into consideration with any type of health intervention. I think that's a really good point. And based on your experience so far, it is the recipe for success in infection prevention. Yeah, endless, endless resources and a lot of time, overstaffed. Overstaffing. And then lots of lots of education and lots of great management. So yeah, I mean, there's, places where you can have pretty good infection control. I'm very proud of the hospital that I work in because

The more that I've seen other systems, I've been realising how carefully everything was put in place that that we do in the system that we're, we're using both for hand hygiene and for environmental hygiene and how much effort this hospital in particular has put on that, on that field where, you know, other hospitals might have, you know, if they don't have Professor Pittet‘s goal is to sort of keep everyone's mind on those those issues, other hospitals might not be as focused on infection prevention. So it's been sort of impressive from, you know, coming from outside in a way in the sense that I haven't developed how things are done in the hospital in Geneva, and seeing how, you know, how to prioritize it is. And also I mean, we can't lie, we can have resources that most hospitals don't have, you know, all of our cleaning staff, with very few exceptions is in house, definitely any sensitive areas are cleaned by people that are in house, I think the average turnover rate for our cleaning stuff is something like 20 years, oh, no, they have a job for life. They have certain patients, they have national level certifications, and they're not just learning about cleaning and management. They're also learning how to read correctly, you know, and how to. So it's, it's, it's really, like a luxury, they're unionised. There are all of these things that play a role in how people identify themselves within the workforce and how closely environmental service workers work with the nursing team, and things like that make a huge difference. So yeah, it's basically at the end of the day, you get what you pay for an infection prevention. So it's fine to cut costs in certain areas. If you can't, it doesn't matter if someone who's cleaning the stairwell doesn't know what they're doing. But maybe you don't want the same person in your operating rooms.

Dr. Marco Bo Hansen  9:57  

And that is so interesting, what you're saying here, because it also makes me think of one of our previous podcast guests, WHO also mentioned the culture for the cleaning staff and their working environment that in general, in Europe and other places, it can be seen down upon this, this task. And what you're actually saying here is that if you can turn it around, make it a really prestigious and important job to do, then you also take upon the responsibility and perform better.

Alexandra Peters 

Yeah, and I think we've seen that really clearly. And that's one of the key things that I personally sort of fight for. I mean, we see just the way that people can communicate up into their hierarchy, you know, the guy that does all the training for the whole hospital, every person who's cleaning can say, Hey, how are you? And you know, he knows everybody by name, almost, I think and every, all the managers at a certain level have had to be cleaners before, you know. So it's really sort of a culture where people work up from the bottom, because otherwise, what ends up happening is that you have a huge high turnover rate, because you're treated really badly. You work long hours, it's hard on your body, because nothing's ergonomic, you're exposed to a bunch of chemicals, and you end up leaving to go work at McDonald's. Because at McDonald's, you get paid the same, but you get a sandwich, you know, so, so there needs to be a big shift everywhere. And it doesn't need to, it doesn't need to mean that everyone needs to have the resources that we have in Geneva, but just there's a lot that can be done. Culturally, I mean, it was in a in a hospital in Turkey once and I was so impressed by I mean, it was a small community hospital, but I was so impressed by the hospitals director knew that when the cleaners, you know, had kids and how old they were, and everyone lived in the same town. And it was, again, you know, the resources weren't great. But you had this really intense family like culture, that meant that the turnover rate was really, really low. And it was really very sort of family oriented. And that was really special. And that was actually better than I've seen it anywhere else in the world. And so that was Yeah, you always get surprised when you visit what kind of things you find and come across.

Dr. Marco Bo Hansen

Exactly. Thank you for these insights. I hope that our listeners use it. We definitely can. There's so much to learn. I want to talk about the clean hospitals initiative. Can you perhaps tell our listeners what that is?

Alexandra Peters 

Sure. I would love to so we're building up these public-private partnerships and trying to get sort of academics and industry and other key opinion leaders or ministries of health or hospitals. All together in one room and learning from each other to push forward our academic agenda. So it's really, it's an academic-led project where we try to focus on what's most important for the field for patient safety for infection prevention. And then, you know, get industries to work with us going toward that. Because at the end of the day, I feel like there's a lot of fabulous companies out there that are doing a lot of fabulous work. And I mean, there's also many, you know, garbage things on the market. We all know that. But that network needs to work together. Because, you know, we don't know your clients the way you know, your clients. And we're not on the ground as much as you are. But we know the science, so we're generating the science. And so working together has a really, really sort of synergistic effect. And so that's what we've been, that's what we've been working on. And we've managed to do quite a lot in the last. It hasn't even been three years yet. It's been quite busy.

Dr. Marco Bo Hansen

It sounds great. Can you come up with some examples of what you have worked with so far?

Yeah, yeah. So we've, we've spoken all over the world, we were at the health care cleaning forum in Amsterdam and Turkey, and then a virtual one in China. I got to speak at the International solid waste Association, World Congress, we had other conferences, such as I clean in Australia, teaching a lot of tele-classes. For example, and just had the opportunity to network with amazing associations and great companies. We've worked on a lot of different projects with our academic Task Force and then other projects with some groups that are all involved in the industry directly. So I've been working on a systematic review, looking at the connection between interventions and environmental hygiene and healthcare-associated infections. We've been working a lot on fake news, we've been starting to map some guidelines and seeing where some guidelines fall short, or they're too prescriptive or not prescriptive enough. And lately, the really big project at the moment is creating a healthcare, environmental hygiene self-assessment framework. So there's a hand hygiene self-assessment framework that was disseminated by the WHO was elaborated by our team before my time. And that was disseminated by the WHO, in three global surveys over the last ten years or so. And we had over 32,000 hospitals around the world that have participated in that. And that what it basically is, is a self-assessment framework that's organized around the multimodal improvement strategy so that healthcare institutions can look at where they're falling short, you know, is it because we don't have alcohol-based hand rub available at the bedside? Or is it because we're not teaching people how to use it? Or is it because our managers aren't cool, you know, it can be any, it can be anything. And that helps institutions sort of analyzing what's going on; then there's a bunch of tools that they created around that to support implementation. And we've seen now over the three global surveys that many institutions are getting better. And that's what's most important, you know, it's not what number you end up with that it's that you are continually working on improvement. And so we're hoping to do that for healthcare, environmental hygiene, which is proving to be quite the feat because there are so many different processes that it has to sort of end the globe. And there are so many differences between countries and between resource levels in what standard practices and all of that. So we're in the initial survey right now; we’ve sent it out to a whole bunch of healthcare institutions in about 150 countries. And we're starting to get data back to learn what they're doing and why and get some more feedback about the survey, do some semi-structured interviews, and then use all that to create the tool. So that's the big project for right now.

Dr. Marco Bo Hansen 

But that is amazing. I mean, but if you want, if you're listening to this podcast, and you want to be part of this great initiative, can you just sign up for it? Or how does it work?

Alexandra Peters 

So we do, we do vet the companies that contact us, so absolutely contact me or contact our project manager. And then, you know, we get in touch, and we talk about it, and we see, you know, whether our interests are sort of going in the same direction, but we were lucky to have some wonderful companies that we worked with, and we're looking to grow over the next few years. So absolutely contact us, and we'll see what we can do.

Dr. Marco Bo Hansen 

That sounds awesome. What about hospitals, public sectors? Can public companies or hospitals also join the initiative?

Alexandra Peters 

So, for hospitals, we haven't gotten to that point yet. That's something we want to do in the future; we’ve been looking at different possible projects or implementation courses that we wouldn't be able to give. But right. As of right now, we haven't gotten to that point yet. Because our group is still small, and we have like ten years of work to do. But as we grow, we want hospitals to be more involved. Yeah, yeah, yeah. And then do training. And then do like, there's this whole massive list of things that we would like to start to work on. And that always depends on how many resources we have and how many hours are in the day.

Dr. Marco Bo Hansen 

Also, the factors you highlighted as really important if you want to make behavioural changes in hospitals. And speaking of behavioural change, we have a loyal listener of our podcast who is curious about your history of working with the topic of behaviour change in healthcare workers, especially when it comes to infection prevention. So how do you communicate about the benefits of improving behaviour in the field where mistakes can have such serious consequences?

Alexandra Peters 

I mean, so there are numerous models of behaviour change, the one that I'm most familiar with personally is the multimodal strategy. And that looks at so five elements. And it's its system change, training and education, monitoring and feedback reminders in the workplace, and then institutional safety climate. And so basically, with behaviour change, it's trying to get the people so on the one sense, it's trying to get them to understand intellectually, why they're doing something, it's trying to make it culturally expected that they do something so that it becomes automatic as well. And that they feel good about what they're doing. And then it's finding different ways to get the sort of result you want in the end. And some of that is practical, some of that is educational, some of that a psychological, and some of that is sort of the institutional framework within which, you know, the people are existing, and the healthcare workers are existing. So I mean, a good idea should be able to sell itself, but that's not really how things work, right.

Yeah.

And so it's self-evident, self-evident to us because we live and breathe infection prevention, but it's not evident to everybody else. And so like the way that budgets work within hospitals, even you know, it's easy to say we need x million dollars to buy a da Vinci robot, and here's how much money we're getting back from every operation. But how do we quantify money that's not spent? You know, how do we identify a pandemic that's been averted? And what budgets are? Is that coming out of, and how do we prove that the fact that we're taking care of our cleaners better, or that we're using products that are, you know, based on scientific best practices and the knowledge that we have today? You know, how do we prove that that's the reason why your hospital saved 40 million this year. And so that's sort of the big thing that we're also trying to work on.

Dr. Marco Bo Hansen

Alexandra when, from my research and clinical experience, also, when we implement our system and try to drive behavior change in hospitals, what I can see is that it's really important with support from the management and to have clear role models. Is that something you have worked with as well?

Alexandra Peters 

Absolutely, yeah. And that's something that we've worked in very often in the training capacity, the trainer's programs that we have been teaching together with the WHO, and the ministries of health sort of all over the world. And usually, the people that we train are either IPC nurses or doctors. And so they're the ones that we're teaching to be role models when they go back to their hospitals. And sometimes we have, I don't know, probably close to 100 different people in the room that come from everywhere in a country to a centralized place for a three-day course. And so it's precise with that in mind that we are helping to develop skills in these people to be role models and to have the knowledge and to have the way of transmitting them. Knowledge in a way that's, you know, inspiring and not punitive and scientifically sound too, you know, improve compliance. And I mean, there are so many barriers to compliance, right? I mean, there's, there are role models, there's not having enough hours in the day, there's being under immense pressure, there's the perception of risk, for example, not thinking like if I'm worried about my patient, now, I can't do hand hygiene, or, you know, tolerability of the product, on your hands. Are there other things that are discouraging you? Maybe your hands are burning? Because it's COVID? And you've been using twice as much as you would normally or, or whatever. But yeah, exactly. And that's a really good point, perhaps also the placement of the dispensers; I think we have become even more aware of the importance of having a strategy and a clear plan on where to put soap and alcohol gel dispensers.

Absolutely, that's key, because I mean, we've seen it when you look at the literature, the difference between compliance before there was alcohol-based hand rub and after. And yes, some of that is that it's much faster to rub your hands than wash your hands. But the other part is that you have to go to the other side of a room usually to wash your hands. So you're only going to do it when it's really important, or your hands feel gross. It's otherwise when I think it was back in 2001, Professor Pittet‘s team quantified how many minutes within an hour an ICU nurse would be washing her hands if she was washing her hands at every moment that she was supposed to be. And it was over half of her workday. Wow. So that's why soap and water were impossible to get excellent advice, not to mention that your skin would just not have any skin anymore, right? You're washing your hands 25 minutes of every hour.

What I found interesting looking into this was that once we started collecting data with the research, I've done. And sort of to look in the literature, very little has been published about the relevance of where to place dispenses. And we could use sensor data to see which ones are the most strategically relevant places and encourage hospitals to put the dispensers in all the relevant places. And that increased hand hygiene compliance significantly.

I'm sure, I'm sure. I mean, we know it should be at the patient's bedside. But further than that, I'm not aware of the literature either. So I'm sure with your system that you have much more data on the specifics of everything then than I do. I would be very interested in

Read it on to the next question related to this. And I've been so eager and looking forward to asking you this question because I want to talk about hand hygiene compliance during COVID-19. And reading the latest studies about hand hygiene compliance during covid 19 pandemics has been published in different places, but still the response literature, and the results show that compliance might not be as high to do with our otherwise expect taking this high focus into account. Why do you think that? Um,

I think we need to be careful when looking at that data and think about why compliance has gone down. We know that half of all missed opportunities for hand hygiene are because health care workers are wearing gloves. Now, if we're in COVID wards, and people are gloved from head to toe, I don't know this for a fact. But I could imagine that there are missed opportunities because people aren't taking off their P.P.E. in the middle of giving care to a COVID patient, which, you know, is understandable. It's a problem, but it's understandable. And then maybe another reason could be overwork or working in really high-stress environments. And we've seen healthcare workers just be, you know, dead at the end of their shifts, and they've seen just the emotional stress of everything they're dealing with, and everything they're seeing could have an impact on that. Or maybe it's because we're not observing and COVID wards. And so somehow, it doesn't seem as big of a threat because, well, oh, well, everyone's been tested for COVID. That's in the ward. So the threat perception might change. No, and I think it's important to remember that like, I wouldn't go blaming the healthcare workers necessarily because, you know, they are genuine, genuinely a group of people that really want to take care of other people. And so When I see compliance drop, there are usually very specific barriers to compliance that are becoming issues. And so what's important during this time is to identify what exactly those barriers are. I know, for example, in our hospital, we used over twice the volume, I'm not sure about the exact numbers, maybe even more than that of alcohol based hand rubs than we've used in other years. So I have a hard time believing that our compliance has really dropped that much. Because we're certainly using a whole lot more alcohol based hand rub, you know, and that, yes, that's a proxy measure. It's not a compliance measure. And I know that they have been doing a lot of observations, but I don't know exactly what the data is. So I don't want to talk about it. But I don't, I'm not sure that the compliance going down because of COVID is sort of as bad of an issue as, as it could be made out to be. I'm honestly not too worried about it. Um, concerning the electronic monitoring in the article, I don't see electronic monitoring at all, as an either or with direct observation. You know, what's great about direct observation is that it can be a teaching opportunity, and really see all of the five moments which you can't necessarily with electronic monitoring. I'm not too worried about the Hawthorne effect, because it's more or less constant. I mean, in you know, it's there. And it doesn't matter, I don't, personally, if I go, and I do observations, I don't care if an institution is at a true level of 50% or 70%. I care about the underlying factors and what directions the trends are going in, and why are the health care workers missing opportunities? And where and can we give feedback, you know, that's much more interesting to me, then, you know, saying you're really at 50%, you're not at 70%. Um, but I think that the future is definitely in or part of the future, in any case is definitely in electronic monitoring systems. And I think that there's a lot of fabulous data that you can get from those, um, you know, like your system that can tell you about where to put dispensers or what kind of movements that healthcare workers are doing. And we tested, one that we came up with where it taught healthcare workers to rub their hands for 15 seconds, you know, and use enough volume. And so I think, with electronic monitoring, you can do all kinds of really interesting, really interesting stuff. So for me, it's not at all, you know, the idea isn't to compete with direct observation, it's just another tool to improve hand hygiene.

And I completely agree, where we can see that electronic monitoring and hygiene monitoring brings value. You can watch the trends you're saying to help infection prevention focus where it's most needed. And then you can set in with direct observations to train in the moment where it is needed. And I think it's a perfect synergy, actually, to save the resources where it's most needed. So because as you say, we are limited on time, and infection preventionists especially. So if we can help them a little bit to focus on where it's most needed, they can go there and train and do everything there. I think that that is where it brings value.

Yeah, yeah, definitely.

I agree. 100%.

I want to go back to you. You mentioned some important effectors in hand hygiene and compliance, and you also said the point of care. And that leads me to the world head hygiene day. So for on the fifth of May, everybody, yeah. So this is just basically for the last 10 years, the World Health Organisation has been celebrating bold hand hygiene day on the fifth of May. And they are bringing together global healthcare, ecosystems to celebrate and hygiene, basically. And each year, there are different topics and areas that are being selected, and I think for this year, and it is actually a call on healthcare workers and facilities to achieve effective hand hygiene action at the point of care. But Alexandra, perhaps you can explain, explain to us what kind of care means in terms of hand hygiene?

Sure. So point of care is really the closest area around the patient. It's the patient zone, it's where the risk of transmission is the highest and it's where most of the time indications for hand hygiene surrounding the patient. It's our sorry. Um, and so our team is celebrating by raising awareness all around the hospital, the shadow, I don't know if you know, in Geneva, but that big water spray that comes out of the middle of the lake. So there's an orange, and then Professor Pittet is here to speak about us, it's going to be all lit up. And so 2021 was designated as the International Year of health and care workers, and focusing on their protection through improved hand hygiene practices is paramount. And it's also a special year because the WHO, and UNICEF got together for this campaign, and it's called hand hygiene for all global initiatives. So it's really a very big campaign this year. And I'd say for the people listening, you know, what can they do and how to get involved. There's plenty of resources on the whole website for what you can do within your institutions, you can post pictures and tweets and posts to our page again, and it's all I don't run the social media thing at all. I know nothing about social media, but they do a fabulous job. And it's, it's very interactive. And I guess what's most important is sort of this concept that Professor Pittet is talking about, which is adapt to adopt. And so basically what that is, is really do what works for your culture and for your content and for your institution, and celebrate and educate and raise awareness, because at the end of the day, every single action counts, and you never know if one action is going to have a big effect at some point. But everything you do, does have an impact.

Aleksandra, when you told me about the funtainer Geneva, I actually got to see it when I was there for the last APEC conference. Can you tell the listeners what epic actually is?

Sure. Yeah, I'd

I love to. So epic is the international conference for infection prevention and control. And it's hosted here every two years here in Geneva. And we get people that are coming in that are coming from all over the world, and especially from developing countries, because there's a whole system of grants to get a lot of participants from, from low resource settings. And yeah, so we are looking forward to welcoming everybody either in person or virtually in Geneva.

Let's see if we can meet both the listeners to the conference this year. I want to close our podcast with a tip. Perhaps as you know, our listeners, hygiene preventionists, healthcare workers, researchers, leaders across the healthcare space. Can you give us a tip if you are a person trying to make a difference in this space?

Um, I would say work with the people that inspire you. And don't be afraid to go take risks in order to do that. If you want a bigger impact, then don't be afraid to start from the bottom. Know how to situate what you're noticing around you into a larger context and then build yourself a bigger soapbox to holler from, but ultimately chances are working in healthcare, you're already making a difference.

That is awesome. Alexandra, thank you so much for your time and for sharing your thoughts and insights. Thank you

So much. It was really a pleasure speaking with you, and

Thank you to our listeners. Be safe and remember to wash your hands or use an alcohol-based hand rub. 

Transcribed by https://otter.ai