David Flicek will oversee the operations of the network's clinics, hospitals, long-term care centers, and Avera@Home.
Avera Health, a regional health system headquartered in Sioux Falls, South Dakota, announced the organization's next COO in a press release last week.
David Flicek will serve as COO of Avera, leading integrated operations for the network's clinics, hospitals, long-term care centers, as well as its home healthcare and hospice company Avera@Home, which serves patients in South Dakota, Minnesota, Iowa, Nebraska, and North Dakota.
"Avera's health ministry has seen significant growth in recent years," Bob Sutton, president and CEO of Avera, said in a statement. "Under David's leadership, Avera has added a new specialty hospital, expanded our behavioral health services, added two family health centers with free-standing emergency departments, extended our Avera Cancer Institute into our regions and replaced several critical access hospitals for our rural communities."
Flicek will officially assume the role of chief operating officer in October, and he will continue in his current role as chief administration officer for Avera Medical Group to ensure a smooth transition. He will also relinquish his title as president and CEO of the health system's flagship hospital, Avera McKennan Hospital & University Health Center. A national search for his replacement is planned for the near future.
Flicek's accomplishments during his 27-year tenure at Avera include being named the 15th top administrator in Avera McKennan's 110-year history, assisting in the development of the Avera Academy, and being a founding member of The Link Triage Center in Sioux Falls, South Dakota.
He led the system's growth initiatives, provided care during the tornados of September 2019, and navigated the COVID-19 pandemic. Through his efforts, the system has developed and expanded numerous partnerships with community clinic groups, as well as city, county, and community hospitals.
"Avera has always been an organization with a strong mission and culture that matches my values. I am proud to have spent 27 years here and to now serve Avera in this expanded role," Flicek said in a statement. "My priorities will include advancing our mission, clinical excellence, physician and employee management, patient satisfaction, and operational improvement. Avera is such a mission-focused and innovative system that I would encourage anyone looking to be part of something larger than themselves to consider joining our team."
William LeCates, MD, FACP, also served as a northern region executive for the health system.
William LeCates, MD, FACP, has stepped down from his role as president and chief operating officer of Bassett Medical Center, a role he assumed in March 2018.
LeCates' leadership skills have been utilized throughout his almost two-decade tenure with Bassett Healthcare. As president of Bassett Medical Center, he was instrumental in guiding the hospital through the COVID-19 pandemic, as well as the corporate restructuring taking place at the same time. In 2021, he began overseeing the operations in another of the system's facilities, Little Falls Hospital in Little Falls, New York
"Dr. LeCates is a steady and thoughtful leader with many years of clinical expertise, deep knowledge about our organization, and steadfast devotion to serving Bassett's communities and supporting our practitioners and caregivers," Tommy Ibrahim, MD, MHA, CPE, FHM, FACHE, Bassett Healthcare's president and CEO, said in a statement.
Ibrahim, in addition to his role as president and CEO, is now serving as president of Bassett Medical Center. Jeff Joyner, who serves as EVP and COO of Bassett Healthcare Network has assumed the role of chief operating officer role for the hospital. Henry Weill, MD, who recently was named SVP and chief clinical officer in addition to his tenure as chief academic officer, will work closely with the hospital's practitioners and quality, safety, and patient experience teams.
LeCates will remain with the system as part of their medical staff and serve as a strategic advisor to Ibrahim.
"We cannot thank Dr. LeCates enough for his many contributions to Bassett, our communities, and our country," Ibrahim added. "On behalf of all of Bassett Healthcare Network, our caregivers, leaders, directors, trustees, and the countless patients Dr. LeCates has touched, we express our deepest gratitude for his incredible commitment to our organization and congratulate him on his accomplishments."
LeCates began his career with Bassett Healthcare in 2003 as a nephrologist and is currently a senior attending physician. In addition to his clinical experience, LeCates is also a clinical professor of medicine at the Columbia University of Physicians and Surgeons. He also served as program director for the system's Internal Medicine Residency Program and was a medical director and vice president of medical affairs at Bassett Medical Center in Cooperstown, New York.
LeCates is a colonel in the New York Army National Guard, and currently serves as the Army National Guard State Surgeon. According to his LinkedIn, he also now serves as executive director of health services for JPMorgan Chase & Co.
Southern Ohio has been the epicenter of the opioid crisis, with record-breaking rates of overdoses and deaths.
In addition to becoming a family physician for Adena Health, John Gabis, MD, FAAFP, CPE, also served as the coroner for Ross County, Ohio in 2009. After noticing a rise in prescription opiate overdose deaths in 2009 and 2010, he alerted appropriate agencies that he thought could help; however, they were not proactive.
As Adena Health's medical director of community partnerships, Gabis took it upon himself to develop a drug abuse coalition that included law enforcement, judicial service providers, child and family services, and other medical groups. For more than a decade, the group has had different iterations, but is now referred to as the Hope Partnership Project (HPP).
The first iteration of the group began in 2015 with the assistance of a grant from the Ohio Criminal Justice System. The funding from the grant paid for a coordinator to come in and assist with putting their plans into action.
In 2019, the group, now known as HPP, applied for and received a $1 million dollar grant from the Health Resources and Services Administration (HRSA) through its Rural Communities Opioid Response Program (RCORP), to be dispersed over three years.
"That provided us the latitude to build our infrastructure of our community partners who provide services for people [struggling with] substance abuse disorder," Gabis said. Adena Health, he added, is a "convenor, collaborator, and catalyst in our community specifically in substance abuse disorder."
The efforts of Adena Health and HPP were recognized by the American Medical Association as one of three finalists for the Foster G. McGaw award; a feat Gabis believes says a lot about the importance of what their community is doing.
"We were part of the epicenter of the drug epidemic that took over the nation. We had a high rate, and unfortunately, still do, of overdoses and overdose deaths per capita compared to other counties and other regions in Ohio and in the country," he said. "We know that no one agency can attack this and be successful, and we know that we don't have enough services available that will provide all our community's needs. So, the only way to solve this problem, or begin to attack it, is to work with community partners."
Previous community health needs assessments have shown that there's a high rate of poverty and substance abuse, with mental health and substance use disorders considered high priority issues for their region. With the onset of the pandemic, Gabis said these numbers continued to rise, with the region setting records every year for overdose deaths.
"[Isolation] is not good for someone that has substance use disorder and often a cooccurring mental health diagnosis," He explained. "Whenever they're isolated, they tend to medicate their emotions with other substances."
One of HPP's biggest successes has been the implementation of the post-overdose response team. A team consisting of a law enforcement officer, peer recovery supporter, and social worker go to the address of an individual who had an overdose within the last seven days. In addition to providing information on treatment options, the team also distributes a dose of Narcan – a nasal spray used to treat a narcotic overdose.
"Most often, the person who overdosed is not at that address, but that's a chance to talk with families and loved ones about what they can do to help that person," Gabis said.
In the beginning, HPP has struggled with tackling the negative stigmas around substance use disorder and the use of Narcan, which some think enables individuals to continue abusing drugs. Gabis explains that the Narcan is meant to guide the individual to the path of active recovery. Today, the community is more receptive to these efforts.
The peer recovery supporters are individuals who previously struggled with opioid use disorder and have been in active recovery for a substantial amount of time.
"They take their knowledge of how they got addicted, how they found recovery, and how they maintain recovery, and they're able to speak to people in similar situations and ways that carry so much more impact that me talking to them, who doesn't have that experience to draw from," Gabis said.
Other successes include increasing the number of primary care providers who can provide medication assisted treatment at the health system from 8 to 30, and the streamlining of the system's emergency department referral process to get patients suspected to have opioid use disorder into treatment with three days.
For other communities or medical systems wanting to take on substance use, Gabis offers the following suggestions.
Organize a get-together with your community to assess what resources the community already has
Implement harm reduction policies, including community distribution of Narcan
Work with and influence other providers to come into your community to provide further assistance
"Since we were part of the epicenter of this crisis, it would be awesome if we had a world class treatment center that served the region," Gabis said. "My dream is that the health systems of central and southern Ohio band together and work to bring something like that to our region so that our communities have hope."
Healthcare logistics is the movement of critical materials such as lab specimens, supplies, pharmaceuticals, and surgical equipment. Some 87% of the 353 survey respondents said the delivery, or failure of these materials to be delivered, affects their work weekly. Another 71% said it affects their work monthly.
Consequently, 32% of nurses have a stash of supplies in anticipation of late deliveries and 27% claimed they'd transported something to another facility themselves to avoid a potential delivery issue, according to the survey.
Other data revealed by the survey indicated that 65% of nurses said they had to collect another test sample from a patient because of an issue or delayed delivery, and 56% had to reschedule a patient's procedure.
The survey's results show a significant financial impact on care delivery, particularly the cost in delaying a procedure. The results also indicate that logistics errors take time away from nurses where they should be delivering care to resolve issues beyond their control.
Our Lady of the Lake Children's Health and Children's Hospital New Orleans, plan to work together to improve pediatric care across the Gulf South.
Our Lady of the Lake Children's Health, a state-wide health network in New Orleans, has announced a partnership with Children's Hospital New Orleans, a nonprofit academic pediatric medical center, to advance pediatric healthcare in Louisiana and throughout the Gulf South.
According to a letter of intent signed by both systems, the organizations plan to collaborate on different ways pediatric health services can be delivered and how to elevate the standard of care in the communities they serve.
"This collaboration would enable us to do more together for Louisiana's children," Kevin Cook, chief operating officer of Franciscan Missionaries of Our Lady Health System, which operates Our Lady of the Lake Children's health, said in a statement. "With recent, significant investments in pediatric healthcare made by both organizations, we believe that we can align respective expertise that will continue to transform the health of our children."
Both systems are united by the belief that new synergies can be achieved to improve access to care and health outcomes for patients. Greg Feirn, CEO LCMC Health, which operates Children's Hospital New Orleans, said in a statement that the partnership will "enhance quality of care" throughout Louisiana, as well as expand access to highly specialized health services. The organizations will continue to discuss the partnership in the coming months.
"The recruitment of national leaders in pediatric medicine, in addition to investments in infrastructure and technology over the last several years, has positioned both Our Lady of the Lake Children's and Children's New Orleans to address the significant health challenges our kids and communities are facing," John R. Nickens IV, president and CEO of Children's Hospital New Orleans. "Creating affiliations and alignments with likeminded institutions enhances our shared ability to deliver a healthier future for children."
Our Lady of the Lake Children's serves the southern region of the Pelican State, offering comprehensive pediatric services and access to specialists. Children's Hospital New Orleans is Louisiana's largest children's hospital and provides the highest level of pediatric care in the state. It also has an academic medical community including LSU Health New Orleans and Tulane University School of Medicine.
"With a shared commitment to academic medicine, together we can continue to deliver unparalleled opportunities for educational enhancement and innovation," Richard Vath, MD, president and CEO of Franciscan Missionaries of Our Lady Health System. "Training the next generation of providers is essential to the future of equitable access to care. We hope to develop collaborative strategies to address population health priorities that improve health outcomes for children and families across the state."
The roles Chris Abe, RN, CIC, HEM, has taken on at the hospital uniquely prepared her for the public health emergency.
Chris Abe, RN, CIC, HEM, always knew that she wanted to work in pediatrics.
Her passion for working with children has persisted throughout her more than 40 years of service in healthcare. Now, as vice president of operations for California's largest children's hospital, Rady Children's Hospital-San Diego, Abe regularly draws on her capabilities as both a clinician and administrator in her leadership efforts.
She began her career as a pediatric nurse at UC San Diego Medical Center, where she proved herself as a leader early on when she was selected to lead the overnight shift within her first 90 days.
"I would never recommend any leadership person to jump in that quickly," Abe said. "But it was a good learning opportunity, and I took it."
For anyone first starting out in their career, it's good to take any opportunity you're offered; whether it's to gain experience, learn, or show what you can do, she added.
She began her tenure with Rady Children's in 1986 as the assistant manager of the medical unit. After a few years she was recruited for a director role at a different hospital, but was convinced to stay at Rady Children's where she took on a new role: project specialist for the vice president of nursing.
"This started to give me a real broad function of the organization because I did policy and procedures, and I started covering for infection control," Abe said. "I started writing newsletters to exemplify what the clinical teams were doing, bringing in new projects; anything that was new that the vice president of nursing or the COO needed."
Her work with infection control led to her gaining control of that department when the hospital's infection control nurse left.
"I found that I had a real passion for infection control [and] infectious diseases," she said. "So much overlaps with policy, and procedures, and the functions of a hospital, so it was a nice fit."
Over time, other areas like occupational therapy and support services fell under her control, and Abe was able to apply her knowledge and talents to a variety of departments.
"That was different. I remember asking the COO if he remembered I was a nurse because these support areas were a little different," Abe said. "But I had also been developing programs that included these departments and their regulatory compliance requirements accreditation company."
Through these experiences, she realized that clinical and non-clinical staff "spoke different languages," and she stepped in as a translator to help everyone understand how important each other's jobs were.
"For my career, I've been fortunate to have been given opportunities to learn and stretch, and then be able to take my clinical expertise as a nurse and be able to pull together that whole picture so that it supports the patient and the people at the beside," Abe said.
Her role in operations is to ensure that patients are set up with the best care. Among the many hats that she wears at the children's hospital is safety officer – where her skills have proved to be invaluable during the last two years.
"My opportunities for leadership have been designed, almost set up, to be a lead coordinator for a pandemic like this because of the departments [I oversee] and the experience I have," Abe said.
With her background in nursing, infection control, and occupational health, she had already created a template for what could be done in a disaster situation. In the years prior to the COVID-19 pandemic, Abe had already experienced the anthrax scare, Ebola, and H1N1 – which made her believe that something like the Covid pandemic could happen next.
"One of the excellent things about Rady Children's is that we are planners," she said. "We feel accountable and responsible for pediatrics."
In November 2019, when COVID-19 cases were beginning to show up internationally, Abe ran a tabletop drill for a pandemic scenario for the hospital, which included leaders and physicians in participation. There were also representatives from the county and the Centers for Disease Control and Prevention (CDC) present.
In December 2019, they held a session evaluating what they were hearing about COVID-19, and in January 2020 they took the additional information being released and decided to adapt the template for the novel virus.
At the time, the hospital was also working with the CDC and state to develop protocol, because there were no protocols in place on taking care of kids with COVID-19. Throughout the pandemic, Abe and the hospital also worked closely with the county in answering questions about the virus and by providing safety information to the community. When vaccines were developed and approved by the U.S. Food and Drug Administration, Rady Children's was one of the first hospitals to start vaccinating individuals.
As information about the virus was updated, sometimes multiple times a day, Abe knew it was important to relay that information to the hospital staff as well as the community.
"To me, it's one of the most important things that I did. What I said to [my teams, the occupation health and infection control team] is 'Our job is to take the fear out, and replace fear with facts,'" she said. "And these personal touches were incredibly important."
The report reviews data from the McKinsey's 2021 Women in the Workplace analysis.
A new McKinsey report reveals notable shifts concerning women in the healthcare industry.
According to the report, the representation of women in management levels is now at 53%, eighteen points higher than the average in other sectors. Additionally, women make up two-thirds of entry-level healthcare employees.
Considering the Great Resignation, the rate of women who left healthcare roles in 2021 was lower than previous years, and lower than the rate at which men left healthcare roles across leadership levels. This includes entry level, manager, senior manager, VP, SVP, and C-suite positions.
"While many factors probably contributed to this outcome, our employee sentiment survey indicates two possible reasons," the report stated. "More women than men reported being somewhat or very happy with their companies, and more women than men would recommend their companies as great places to work."
External hires increased representation, particularly in the C-suite, however there is still more to be done. The staffing shortage in the industry was struggling prior to the pandemic and has been further exasperated over the last two years.
"The ongoing stress of the COVID-19 pandemic threatens to undo progress in promotion and attrition rates, potentially setting female representation and advancement in healthcare back by several years," the report stated. "If women leave the workforce, miss out on promotions, or both, that will hinder efforts to reach gender parity in the C-suite."
Data shows that the representation of women in decreases from the entry level (67%) to the C-suite (29%). Promotion rates for women were either on par with or slightly lower than those for men through the senior vice president level, yet decreased when it came to promotions to C-suite roles.
Women of color, who make up almost a fourth of entry-level roles only occupy 5% of C-suite roles. The report called the attrition rates for women of color at the manager (28%), and senior manager or director level (17%) alarming.
"Compared with White women, White men, or men of color, proportionally more women of color reported spending time on diversity, equity, and inclusion (DEI) efforts, but they are the least likely to say that these efforts are well resourced at their companies," the report stated.
The report also noted that respondents claimed that they didn't feel supported in their DEI work. Of those surveyed, 16% said that when they would speak up about bias in the workplace, they'd be retaliated against.
Disproportionately, 51% of women said that they put aside time to learn about the experiences of women of color, including reading, listening to podcasts, or attending events, while only 35% of men surveyed did.
The report recommended actions to take the improvement of retention and promotion of female workers. These actions include:
Mitigate attrition by ensuring reasonable workloads, encourage boundaries, and provide greater flexibility at work for women.
Use open positions to advance DEI goals through external hiring and equitable promotions as mechanisms for change, as well as implementing bias training
Maintain a deliberate focus on opportunities for women of color, including examining the organization's evaluation and promotion processes
"Gender parity and proportionate representation of women of color in healthcare at the top levels remains aspirational," the report said. "Although there are reasons to celebrate, healthcare stakeholders may consider what they can do to rebalance the scales."
The acquisition, expected to be finalized this summer, will transfer ownership of the physician group from Saint Louis University over to SSM Health.
SSM Health and Saint Louis University recently announced a new agreement for SSM Health-St. Louis to acquire SLUCare Physician Group in a move to "deepen their partnership to advance health equity, strengthen medical education, and improve the health of the St. Louis community and beyond."
SSM Health, a nonprofit, Catholic health system headquartered in St. Louis, Missouri, and the private, Jesuit research university have worked together for decades, along with SLUCare, to deliver care at SSM Health Cardinal Glennon Children’s Hospital, SSM Health St. Mary’s Hospital and, more recently, at SSM Health Saint Louis University Hospital.
"Both SSM Health and Saint Louis University School of Medicine have a rich legacy of providing hope and healing to those in need across the St. Louis community," Laura S. Kaiser, FACHE, president and CEO of SSM Health said in a statement. "We are thrilled to be taking this next step in our shared mission to ensure every patient gets the best care possible, while keeping that care affordable for the individuals and families we serve."
The acquisition, expected to be finalized this summer, will bring the academic medical expertise of SLUCare together with SSM Health's community-based healthcare model, and will transfer ownership of the physician group from Saint Louis University over to SSM Health following the finalized transaction.
"The integration of SLUCare into SSM Health will be one of the most comprehensive fully integrated academic and community-based physician groups in the region," Dr. Fred P. Pestello, president of Saint Louis University, said in a statement. It will also give the community seamless access to improved care, from primary and preventive services to specialized procedures and clinical trials.
"Saint Louis University School of Medicine has a long tradition of excellence in academic leadership, educating the doctors and scientists of the future, while advancing cutting-edge clinical research and patient care," Christine Jacobs, M.D., dean and vice president of medical affairs for the School of Medicine said in a statement. "This partnership will expand the scope of our primary and specialty healthcare, allowing greater access to clinical trials for our patients, while we educate diverse and committed future physicians for our region, and grow our research in the School of Medicine."
According to the organizations, current patients of SLUCare Physician Group providers won't experience any disruptions in the care they receive or locations they visit for care.
"Working together, we can better meet the comprehensive needs of patients, as well as employers and payors who are looking to partner with health systems that can offer the full range of healthcare services, including expanded breadth of specialists that an academic medical practice can provide," Jeremy Fotheringham, regional president of SSM Health, said in a statement. "Through seamless access and care coordination we'll be able to deliver unparalleled value and convenience."
As many rural hospitals struggle to provide the care and treatments patients need, OSF Healthcare and SSM Health have formed a partnership that will increase accessibility to patients in Illinois.
OSF Saint Anthony's Health Center is in Alton, Illinois and is the furthest south of 15 hospitals in the nonprofit, Catholic health system, OSF HealthCare. To get to its flagship facility, OSF Saint Francis Medical Center in Peoria, it would take a two-and-a-half-hour, 160-mile drive.
To bring patients specialty care and treatments they wouldn't readily have access to, Saint Anthony's began looking at other Catholic health systems in their market whose values and mission aligned with theirs. Two years ago, OSF Healthcare began discussing a possible partnership with SSM Health, a nonprofit, Catholic health system headquartered in St. Louis, Missouri.
Through the systems' new strategic affiliation, Saint Anthony's patients will now have access to SSM Health, increasing accessibility to the network of specialty and subspecialty physicians.
"The principle of this relationship is to bring services to our community that we're unable to support in a community hospital, and then create an integrated network of referrals," Saint Anthony's president, Jerry Rumph, recently told HealthLeaders.
The collaboration will help St. Anthony's build depth when it comes to physician specialties, Rumphs said, which will enable the organization to bring specialists and physicians to their campus to provide services they wouldn't normally have access to provide to their patients.
"The second element is to create an aligned network of subspecialists that we can refer to, and part of that is for continuity of care," he continued.
As both systems work together, patients will be able to move back and forth between St. Anthony's and SSM Health's facilities in St. Louis, sharing medical records to coordinate care, diagnostics, and follow-up appointments. There are also plans to incorporate telemedicine services so that patients don't have to travel.
The first collaboration will see Sridhar Kumar, MD, a cardiologist at SSM Health Saint Louis University Hospital, step into the role of chief of cardiology at Saint Anthony's. Where Saint Anthony's was previously only able to offer basic cardiology services, Dr. Kumar will expand their services to include a wide range of cardiac interventions, treatments, and testing, giving patients access to care and treatment that they would have had to find elsewhere.
Partnerships like this would serve as a great template for other rural or small community hospitals, Rumphs said.
"Especially in the remote areas, that would be very beneficial for patients because a lot of families, if they do go see a specialist in a large community, they have to travel just to a doctor's appointments," he said. "I can see this being a real opportunity to provide this level of care to people in smaller communities."
Editor's note: This story was updated on May 5, 2022.
Efforts of organizations to foster an inclusive workplace for neurodivergent employees are ambitious, with technology-oriented companies taking the lead, he said.
"Some of these organizations … I would hold up as really excellent organizations. I think the efforts at SAP and Microsoft are good, ambitious, and growing, but I would say the jury is out—but not out in whether autistic folks can be really effective employees," he said. "I'm not concerned about that, so much as I am about whether people can have actual careers coming in through these initiatives, or they're being placed in jobs that are otherwise difficult to fill."
Increased awareness
Workplace awareness of autism has grown as children grow up with friends who are neurodivergent, or as adults already in the workforce have identified as autistic, Vogus has said.
Individual familiarity and familial connections to autistic and neurodivergent people have led to several entrepreneurial organizations where most of the workforce is autistic. There are also targeted employment programs in larger companies such as JPMorgan Chase and Microsoft.
There are tendencies across the autism spectrum where many individuals have strengths when it comes to structured, analytical processing and others exhibit artistic strengths.
One frequent barrier to organizational understanding of autism is the "double empathy problem," Vogus said.
"People who are autistic were initially and erroneously thought to lack empathy or have what's called 'weak theory of mind,' but what's really going on there is that neurotypical people and neurodivergent people are processing the world in fundamentally different ways," he explained.
"So, a lot of times, what is the biggest barrier to successful employment for autistic folks across a range of professions is that divergent, that double empathy problem where neurotypical and neurodivergent people have trouble taking each other's perspectives," he said.
This is where being clear in social cues and interactions can help. In his research, Vogus has found that employers and managers will oftentimes mischaracterize their autistic employees because they aren't performing a task the way they, the employer or manager, normal would.
He also notes that the healthcare industry has lagged behind others when considering neurodivergence, which may be due to the stereotypical understanding that people have of social interactions and how healthcare is delivered interpersonally.
"I think there is a whole IT infrastructure for the healthcare world that may even be populated with neurodivergent folks who don't feel comfortable to disclose that they're neurodivergent," Vogus said, adding that this is something that's come up in research as well.
Vogus' experience watching his son, who is autistic, grow up and wanting to ensure that he's able to pursue his interests freely and live life the way he wants drives his advocacy and efforts. He has research being reviewed that examines the relationship manager-employee relationship and its influence on employment success.
"One of the things that I think is really promising about neurodiversity in an organization, much like it is with any form of greater diversity in an organization, is that you give different perspectives, different lived experiences, different ways of processing and experiencing the world—that enriches any organization," he said. "It makes them more adaptable, innovative, more flexible, able to do more than they could with a homogenous workforce."
There's still work to be done for workplace inclusivity and Vogus offers a few tips for companies wanting to improve their neurodiversity practices:
Increase organizational understanding of autism
Move away from practices that can be seen as exclusionary or discriminatory and embrace new ways of thinking and lived experiences
Providing clear expectations for job performance, as well as consistent and direct feedback
Offering "environmental modifications" at work (for example, noise-canceling headphones)
