TH: Now that you've been at it a few years, what has surprised you about your job? What do you know now that you didn't know then?
JK: That's a difficult question to answer. I have to think about that. (Pause.) Well, obviously, one of the biggest surprises was that there was enough of an employee feeling that they needed to have union representation. That was something that clearly was a surprise to me. What's really strange about that is that the people are so friendly here. This is a group of very good employees. They're very much into the care that they provide to the patients. So, in that atmosphere, I guess, that was a surprise to me. It was not something I would have counted on. Other than that, I really don't think there really have been many surprises here.

John E. Knox Age: 51 (turns 52 on Thursday) Occupation: President and chief executive officer, The Finley Hospital, since January 2002. Family: Husband of Karen, a registered nurse and nurse practitioner. Father of Heather, a mechanical engineering graduate, and Erik, a senior at Wahlert High School. Hometown: Detroit. Education: Master's degree in business administration, University of Detroit, 1981.. Master's degree in biology, Wayne State University, Detroit, 1977. Bachelor's degree in biology, University of Detroit, 1975. Various advanced training, certification and internships. Professional associations: Fellow, American College of Healthcare Executives. Community leadership: Hills and Dales board, Dubuque Rotary Club, Junior Achievement of the Tri-States board. Hobbies: Piano, reading.

TH: As you see it today, what do you consider Finley's strongest attributes?
JK: Unquestionably, it would be the people. I think the reason that Finley is successful is that the people are all about providing the best care possible for the patients. You see it from the nurses to whatever staff you want to pick. Whether it's housekeeping, dietary or the physicians, they're all very dedicated to taking care of their patients, and nothing gets in the way of that. I think the other positives are is that this has been a well-maintained facility. The technology. We've kept up with the technology. There is not a shortage of top-notch equipment here. So those are all positives that I think have helped Finley.

TH: What do you see as areas for improvement?
JK: Well, there are certain things that we need to add here. We've started to do some of that. For example, we added in-patient acute rehab services for those who have had strokes or are recuperating from certain orthopedic procedures. Recently, we added sleep studies here. So we're looking at things that fit in, that is care that the community needs and fits in with Finley's mission. I think we always have to look at that, because health care, just like every other business, has to be able to grow to survive. The other piece is - to stay alive, we have to continue to be very careful of our costs and try to control that as much as possible. So we've done all kinds of initiatives to try to keep our supply costs down, to look at how we can run more efficiently so that we can generate the bottom line that we need to keep reinvesting in the facility and upgrade it, buy new equipment as we need to and pay competitive salaries and so on.

TH: Earlier, you referred to the unionization of nurses that occurred here at Finley. What is that status of contract negotiations?
JK: Both sides of the table have given complete proposals to each other. We have basically walked through all the articles that have been presented by SEIU (Service Employees International Union), which is the union representing the nurses now. There are a number of conditions that we've reached agreement on. There are a lot of them that are basically in counter-proposal state at this point, where we have made an alternative proposal to them. We are making progress, but we have some serious differences at this point that we really to get much closer on and one of them is the economic packages because they really presented a very expensive package that the hospital couldn't possibly meet. So hopefully we'll reach some middle ground on that and come up with a reasonable compromise. We're hopeful that we can get the contract done relatively soon here because it has dragged on. But we're negotiating in good faith and we hope to close the contract.

TH: In mid-January, the economic proposal was in the range of 21 percent over three years. And at that time, you had said if we have to pay that, Finley would close.
JK: Well, here's the way I look at it. We went and sat down and priced out what the cost would be of their proposals. It would add an additional $4 million-plus a year. There were some parts of their proposal we had difficulty even costing out. But the part that we could definitely cost out was over $4 million a year, in terms of extra cost. Hospitals in Iowa, including ours, operate on a pretty thin margin. We're a not-for-profit institution. We typically target in the area of 31/2 percent operating margin each year just to make sure we can replace ourselves and keep up with the equipment. That's not a lot of money. If you look at our case that's in the neighborhood of $2.5 million a year, bottom line. It doesn't take much to figure out if you add $4 million in costs and you're generating $2.5 million at the bottom line, you're not going to be very viable for very long. While we are very interested in making sure we're paying competitive salaries, we always want to do that, we want to be fair with the nurses; we also have to think about the long term future of Finley Hospital and everybody else that works here. Not just the nurses. That's why when I say it puts us at risk, the math clearly indicates that it puts us at risk.

TH: In many institutions, when there's some unrest - in terms of a union contract, and negotiations - there can be impact on customers or, in this case, the patients. What's your assessment on the impact of the nurses' negotiations on actual patient care here?
JK: I think it's what I've been most impressed with. While the negotiations have certainly not been easy negotiations, the nurses in this facility have conducted themselves totally professionally. We look very closely at patient satisfaction scores. We participate in Press Ganey, which is a nationwide benchmark of patient satisfaction. A lot of hospitals use the same survey, so we can very easily compare our results with others across the nation in the same size category. We're among the highest in the nation. As a matter of fact, just a couple of quarters ago, we actually passed the threshold where we were in the 97th percentile in the country, so we were in the top 3 percent for patient satisfaction. They also rank how the food was, how clean the hospital was. I think all those things are contributing to the fact that people are very pleased when they come to Finley. It's largely due to the fact that nurses still are focusing on giving the best patient care possible here. So even though we're in these negotiations, they've been very professional and done a great job. And not just the nurses, but everybody else. We are busier now than we have ever been. That tells me also that we must be doing something right.

TH: If I were allowed to roam free and ask some of your key people around here, "What kind of boss is John Knox?" What do you think they'd tell me?
JK: It's hard for me to gauge that. I think that for sure they would tell you that I'm fair and I'm honest. Beyond that, I couldn't begin to tell you what they would say.

TH: I visited with Rusty Knight (of Mercy Medical Center) a few months ago. I asked Rusty - and I'll ask you the same question: How would you describe the relationship between Mercy and Finley?
JK: I think it's certainly very competitive because we are, again, in the same business, providing the services to the same population. But I think it's also very cordial. Rusty and I frequently see each other. I have the highest regard for him. He's a very good administrator and very honest guy. Where we can work together; we have tried to do so. One effort we were both involved in was this community health center, where we were trying to help other folks in the town raise grant funds so that we could take care of those folks that don't have financial resources. Now, we haven't been successful with that, but certainly both parties, Mercy and Finley, were very interested in making that happen. But as you can well imagine, given the fact that we're in the same business providing the same services, the opportunities for cooperation at not all that great.

TH: You're busier than ever, and one reason for that is the recent change in the John Deere insurance plan - a change generally from Medical Associates and Mercy - and that impacts you. What has been the impact on your organization with that change in the John Deere coverage?
JK: Actually, we've tracked very closely because it started in January, the switchover. We've tracked closely how much of the business that we've seen has been John Deere. It's a little bit under 10 percent. So when we look at the actual inpatient admissions to the hospital, it's amounted - and this is an average - but it's amounted to about two additional in-patients a day. That's not accounting for our big jump in volume. I don't know if it's one of those cycles that we're going through, where a lot of folks are getting sick and we're just seeing that, or whether there's been some sort kind of halo effect now that we've got John Deere, some other folks have jumped on board. But clearly, there's more than just John Deere at work here. We've seen an increase in everything.

TH: In covering the transition, we heard from people who are concerned about the cardiac piece of this, particularly as it related to emergency cardiac care. With this change in the John Deere coverage, what happens if someone covered by John Deere is experiencing chest pains and a possible heart attack? What's the chronology?
JK: Well, a couple of different scenarios. If it's an emergency, if they come in and it requires emergency cardiac care, a rush for open-heart surgery, as I understand it, John Deere covers those folks who go to Mercy then because it's an emergency. That's taken care of. The real issue is the ones that indicate that they have heart problems, they're going to need open-heart surgery, but it's not an emergency. And that's what most of the open-heart cases are. They're not emergencies. They're elective cases; you plan them. At this point, there is not an agreement, as I understand it, with more the Medical Associates piece. As I understand it, Mercy has - and Rusty could tell you better - but as I understand, Mercy has reached an agreement with John Deere on open-heart but Medical Associates has not and, of course, they've got the surgeons that do the cases. So at this point, until that happens, the John Deere folks who need elective open-heart need to go to facilities that are approved. And those are in the Quad Cities or in Waterloo, Allen Hospital. Those are the only options they have right now. One of the things that I think is important for folks to understand is that when we did this deal with John Deere, we did not cut out Mercy from the open-heart piece. We basically said, "We obviously don't offer open heart so you need to work out an arrangement however you feel is appropriate to handle those cases." So there was no intent to keep Mercy out of this. But they have to reach agreement. They have to cut their own deal and until that happens, then John Deere folks have to go to facilities that are approved.

TH: And Waterloo and the Quad Cities would be the closest ones?
JK: Those are the closest ones that I'm aware of, yes.

TH: Just to recap: If someone does have an apparent emergency situation - if they end up at Mercy, which does have the open-heart surgery - it's still possible to have this emergency care in Dubuque. Nobody is going to be screaming down Highway 20 in an ambulance heading to Waterloo before they can have an emergency open-heart surgery?
JK: No. John Deere's plan covers emergency open-hearts and those can be done at Mercy. If we had somebody in our emergency room that we did the testing on that needed emergency open-heart and they're OK with Mercy, that's where they'd go.

TH: What's ahead for Finley? What do you see in five, 10 years from now in terms of facilities, patient care? What's your vision for Finley in five to 10 years?
JK: Well, I would obviously like to see Finley grow and develop. One of the areas we're really focusing on is moving toward all private rooms for Finley. That's not just a cosmetic change. There's a lot of evidence in the literature that that improves patient care. It reduces what we call nosocomial infections, which are infections you pick up in the hospital. Without a roommate, the risk of infection drops. There's better morale for the employees because they're not always trying to juggle one patient into a different room when there's different sexes or there's problems. Patients recover faster because rooms are quieter at night without a roommate, and family members can visit more freely since the room is not being shared with another. So we think moving toward private rooms is an important piece. We are looking at this point at how we can best accomplish that. Of course, we want to have the reserves and the cash to be able to do that. I think that's an important piece. In the meantime, we are really trying to renovate areas where we think the patient flow could be a little bit better. From a physical facility standpoint, we could do a little bit better job of handling the patient. As I mentioned before, we're looking at what services can we provide that we're not providing. We're looking at new technology, for example, in the radiology area. We just put in a new 16-slice CT scanner, which does a much better job of imaging patients. I think what we'll see down the road is more and more non-invasive testing done. People won't have to go through the same sort of invasive test that they do now to find out what's wrong with them. We'll see a lot more of that. I think the key for Finley is do the best job we can from a staff standpoint, but also keep the physical facility up and look at where can we implement new technology that will do a better job with the patients. And then the other piece we do a lot of in the community, which goes back to that community benefit piece we talked about. What things can we do to keep people healthy so they don't even have to come in the hospital? That's where the diabetes center comes in. That's where we do health screenings and we do education out in the community and we'll continue to do that as well.

TH: Some of that is sort of counter-intuitive. I realize that this facility wouldn't exist if people didn't want to help other people. But from a business perspective, where does Finley derive some revenue from some of these outreach programs? If you're successful, your patient count is going to go down.
JK: Right. You're right. It is counter-intuitive and we don't get reimbursed for it. That's the difficulty. Again, we're a not-for-profit institution and right in our mission statement, it says we're all about trying to improve the health of the people in the tri-state area. Well, if you're working on health, then you don't just worry about when they get sick and they're in the hospital. You worry about trying to keep them out. So even though we don't get paid for it, we do think it's our job to try to keep people healthy. And we would love to see a change in the reimbursement that would reward us for doing that. That's why we keep trying to talk to congressmen and representatives about changing the whole reimbursement scheme, because when you look at it, what we get paid for is taking care of people when they're really sick. We don't get anything for trying to keep them out of the hospital. I think that's something that we really need to try to change the focus on.

TH: How optimistic are you that that's going to happen, given the political scenario and the ingrained nature right now of how we pay for health care?
JK: Not very. I think it's something we need to keep working on. But, no, not very. I think the system is so ingrained that it's going to take a lot to change it. But when you really look at it, when people, and the whole country is focused on health care, its cost our employers to have increased costs and it sometimes costs this country to be non-competitive in certain areas, but if you really want to reduce health-care costs, that's where you've got to start because that's where all the money is. I mean, people in this country eat too much, smoke too much, don't exercise enough. Those are things that if we could change, we could save some real dollars in this country.

TH: Are there hobbies or leisure time activities for you?
JK: Well, the thing I love to do most is play the piano. I have done that ever since I was a kid back in first grade. Took lessons for many years. Just love sitting down at the piano and spending a couple of hours playing music. I like to read. That's probably the other favorite pastime, but piano would be at the top of my list.

TH: What music do you generally like to play?
JK: My favorite piece of all time is "Rhapsody in Blue," by George Gershwin, so I routinely play that. I love Rachmaninoff. Little bit more complicated than I like to play, but I do love his music. Those are probably the two I like the most. A lot of popular music I like. But George Gershwin amazes me - how a guy could write all that music and be so young. It just amazes me that anybody could have that kind of a mind.

TH: So, is this the last stop for you before retirement? Or do you see possibly another move in your career?
JK: Well, this is the third hospital that I've run and I'm getting to my mid-50s, so I would think that this may be my last stop. I still think there's a lot to be done here at Finley so I surely don't think I'm going to get bored any time soon. As long as I'm not bored and I think I'm making some contribution, I'm happy. And I like Dubuque a great deal. I was in Michigan all my life before I came here. I like Michigan, but the difference is that things are, I think, a little bit more comfortable here. People are friendly here. You don't have to - I hate lines, I hate congestion. The fact that you can go places and get in quickly and not have to fight traffic here, and there's so little crime. It's a nice place to live. It's been great for my son; I think it's been a great place to raise him.