Economic Behavior Emerging from a Transformed Structure underlying the Puerto Rico Medical Center System

           A Proposal : Transformation of the Puerto Rico Medical System Model and  Economic Results 

Revised August 28, 2017

Nilza I. Cruz Ruiz

939-644-7683

    
"There is a gap between appearances and reality. The degree
of catastrophe is increasing"  - Nilza I. Cruz

During the past weeks, I have written about Complex Systems, what
characteristics these systems portray, and most important: emerging results
that in the case of the Puerto Rico Medical Services Administration, are no 
surprise, that is; given the existing landscape. One that hasn't changed for at least
the past thirty (30) years.

It is time to focus on changing the underlying structures that give rise to existing

emerging results. Health services are critical and essential.

We need to create new conceptual models, validate with "real world" circumstances, and implement them.

The Alternate Model should  promote forecasting results, in addition to data intelligence and levels

of adaptiveness. Management is not about reacting  to situations and taking action (s),

it's about  continuously creating and validating new models within the health sector based on

technology, sustainability, interrelations, accountability, big data, and data intelligence.

All, strategically centered on promoting the best patient care focused

on prevention, in a non political manner. We have the tools and top health related and

professionals from the social sciences and humanities to  comply with this goal. 

I. Introduction

As former General Administrator for the  Puerto Rico Administration for

Medical Services(ASEM)  for the period of  2013 to 2016, I was able to

dive into and navigate within the system's complex and challenging structure,

social system, financials and operations.

Therefore  understanding the underlying factors and

variables that drive this health system, emerging in unsustainable economic results.

You see, the saying the "detail is in the devil" is completely true!

This provided me with the  motivation of complementing my academic back round in

pure mathematics, statistics, probability, information theory and business

administration with complexity science and related agent based modeling.

This, with the motivation of assessing existing landscapes and creating baseline financial scenarios

in order to research alternate models within different organizational landscapes that

could lead our healthcare system and patient care to the next level;

especially in the government sector in which we are presented with true challenges.

The current government health system is operating on a day to day basis,

with cash flow and liquidity constraints, along with debt-services accumulation 

which is escalating exponentially.

II. Context

  

Today's presentation will consider the following core concepts  within the Complexity Science and Agent Based Modeling (within complexity) schools of thought:

      

       1. Emergent Phenomena,  is how we describe the organized pattern that results from interactions of the distributed agents within the system. For the purposes of the following study, the "system" is the Puerto Rico Medical Center System (PRMCS). The organized pattern will be presented in terms of it's economic results for the past fifteen (15) years, present [FY 17, (considered  the baseline] and projections for the next ten (10) fiscal years should the structure of the existing system and its underlying components remain unaltered. Agents are represented by the PR Department of Health, Administration for Medical Services (ASEM), PR Medical Science Campus, the Hospitals within the Medical Center [Trauma Hospital (under ASEM governance), University Adult District Hospital, Pediatric University Hospital and the Cardiovascular Hospital] ,  and Financing Methods (Universal Third Party Payer System, State Contributions, Federal Medicaid and Medicare Contributions and variances). Each agent is guided by sets of rules, regulations, and strategies. Also, there are levels of agents within each agent . For example, within each hospital, there are departments, and within each department, there are employees. Most of the hospitals, are under the governance of the Department of Health (agent), and this agent is under the governance of the Governor of PR. And yes, each "agent-sub level" also follows different sets of rules and often strategies as well. 

       2.  Structure, rules, interrelations and feedback at the micro-level lead to an emerging pattern (in this case, economic) at the  macro-level.

III. Operating Results for the Puerto Rico Administration for Medical Services (ASEM) -  1993 - 2015*

 *even though these results correspond to ASEM, the research findings and results below correspond to the Puerto Rico Medical Center System as described . Sources of data : audited financial statements and Meditech Information System .

IV. Baseline Study Regarding existing Puerto Rico Medical System Structure:

 * Sources of data: Audited financial statements, Meditech Information System, PR Office of Management and Budget

Key Research Findings

• Since its inception, the Puerto Rico Medical Center (PRMC) has failed to incorporate a business model that could fulfill its economic commitments.
• The solution proposed by various administrations has been the integration of some government hospitals that make up the PRMC
• under the assumption that a single governance and certain economies of scale (not specified) could solve the situation.
• However, even with the intended integration the financial projections for the next ten years (10), suggest a fiscal gap of five hundred
• and sixty million dollars ($560,000,000), assuming the present time organizational DNA of the PRMC within its baseline
• (includes service debts-GDB loan).
• The baseline results reflect the need to substantially decrease the number of patients by one hundred and sixty six thousand two  hundred and sixty four (166,264) or eleven percent (11%) for the described period. This, to balance the budget without additional economic resources from the local or federal government. The percentage (11%) will increase should ACA funds decrease by one billion ($1,000,000,000) and/or the baseline structure is not transformed.
• Accumulated debt services (excluding GDB loan) plus losses are projected to escalate to more than one billion dollars ($1,000,000,000) by 2027, assuming the same historical liquidity dynamics based on current dollar value for the ten (10) year time period.
• Due to the circumstances slated, an alternative roadmap is provided (based on optimal combinatorial methodology) for reaching higher peaks (Model I) within the organizational landscape.
• Once the model is implemented, assuming a cut of one billion dollars ($1,000,000,000) in Medicaid, and non increase in state contributions from the actual level, the simulation algorithm used suggests : surpluses from operations, and enable sustainable supplier and government account payables in a thirty day or less ( ≤30) period. 
• Surpluses will  offset debt payments with suppliers and government agencies like retirement and electrical energy

Baseline Government Health Sub-system Model

Agent Components

Baseline Model Agent Causal Loop Interrelations

Baseline Emerging Economic Results from Agent Interactions:

ten (10) Year Forecast

Why has the System Produced Unsustainable Economic Results for the last sixty (60) years?

1.The PRMC is a Complex System. That is, a nonlinear system defined by the interaction of multiple independent

agents (e.g ; people, institutions) that require adaptive strategies, from which goods and services necessary for the

treatment of conditions associated with tertiary and supra-tertiary medicine could emerge.

2.The coordination of operational logistics and resource allocation occurs through rules and agreements (contracts) between agents and

institutions and these in turn do not necessarily positively correlate with an equitable share of risk, income, expenditure and priorities.

3.The non-equilibrium between these variables is a macro by-product of the interactions and behaviors of different governance structures for each one of the component units and the health ecosystem along with the internal political power they display relative to other institutions.

Model I Proposal - Organizational Structure and Agent Illustration -
Puerto Rico Medical Center Integrated System (PRMCIS)

Model I - Transformed Puerto Rico Medical Center Economic Results (PRMCIS) *

* Revenue (state and federal assignments) ,expense and structural  assumptions included as per Model I proposal

Iteration I - Conclusion

1. Model I, is just a peak within the organizational landscape roadmap that could be achieved in a period of no more than three (3) years if decisive organizational and financial transformation actions are taken in the short and medium term.
2. The actual structure would be transformed promoting a framework that would minimize internal politics dynamics and maximize

operation results and efficiencies based on non-legacy technology. Duplicity of human capital, physical infrastructure and other resources,
will be eliminated since the traditional administrative functions will be streamlined.

3. As a direct function of a transformed structure, the economic behavior would generate

surpluses from operations, and enable sustainable supplier and government accounts payables

in a thirty (30) day or less period.

4. The significant impact in terms of administrative and medical related functions will be that a substantial part of the related

processes that are completed in different physical environments with outdated technology will be done through high mainstream

technology. Since the health system, globally speaking, is subject to substantial operational transformations, technology

providers in this matter have been approached.

5. Model I could be ground work space for technological trails (concept similar to clinical trials) with minimal cost (in kind)
for the Government of PR. Global providers are willing to move ahead with the project.

6. In addition, Model I requires the flexibility of using human capital as a functions of the duties,
time and environments required by the different sub-components of the system.

Complex Systems oscillate between Randomness and Order. This does not mean these Systems are Stable or Self-Equilibrating. Especially when factors as internal politics and governance issues are embedded within the landscape.
These Systems go through Phase Transitions. Management of the Puerto Rico Medical Center System and higher levels need to understand this... and take corresponding measures. This is a System of Health Services, which makes it truly unique.

An Introduction - Complexity, Emergence, and Feedback

                                  An Introduction - Complexity, Emergence and Feedback





July 10, 2017


I. Traditional Management Thinking and Universal Education

As leaders or facilitators, it seems that from a general standpoint, actions related with strategic planning, plan implementation and follow up or "continuous improvement" represent the core elements for the success of organizations within the private or public sectors. Many of us have pursued  graduate or post doc studies in areas related with business, science (natural, social), law, engineering, technology or a mix of them with the main objective of achieving the necessary intellectual knowledge to make the organizations we represent "successful". The foundation of said knowledge is mostly acquired through a universal education system vehicle better known as the "University". In it, we follow the path of framed curriculums according to the areas of study we choose. But the problem is, that said areas of study offered by the "University"  emerge from the definitions and mixes of concepts related with history, philosophy, arts, sciences ,humanities and theology. These areas would then be "locked" into individually designed standard programs  within a faculty. For example, a degree in physics within the faculty of arts and sciences. In this case,  physics is  defined as: the branch of science concerned with the nature and properties of matter and energy. The subject matter of physics, distinguished from that of chemistry and biology, includes mechanics, heat, light and other radiation, sound, electricity, magnetism, and the structure of atoms.
So, if we study physics, we'll be part of an intellectual journey related to a "branch" of science focused on the "natures and properties of matter and energy". Our actual education system obeys a "pathway behavior" since our elementary and secondary school studies. This system has trained our minds to focus on individual fields of study, limiting our natural abilities to create and think outside of framed boxes by means of systematically interrelating emerging knowledge from different subjects. Systemic thinking would lead us to think differently and obtain non-traditional better outcomes based on empirical data in whatever we do. Imagine us, all members of an existing society, systematically thinking and executing this way?

II. A Holistic Universal Education System in Need; Our Responsibility

In 1900, Louis Bachelier , physicist and mathematician, who arrived in Paris at his early 20's in 1892, had laid out the mathematics of financial markets. The basic idea of his thesis was that probability theory, the area of mathematics invented by Cardano, Pascal and Fermat at the 16th and 17th centuries, could be used to understand financial markets. Bachelier, by 1900 had worked on the mathematics that Paul Samuelson (economics professor at MIT) and his group of students were working on in 1955 for purposes of adaptation in economics. Samuelson, nor many of his peers, knew anything about Bachelier nor his critical contributions to economics and finance, until 1955! I find this incredible considering the Universal Education System in the US! Indeed, our universal education system should have a new non-traditional holistic approach, and some universities are already changing. But for now, the challenge is ours as individuals. We need to read and educate ourselves in different subjects, concepts, and interrelate with existing knowledge. We need to understand the history of our greatest painters, musicians, scientists in the social and natural sciences, and so forth. It is our responsibility to adopt this systematic "meeting of knowledge" thinking approach, model, and deploy it in our organizations, especially in the government. We need to free our minds by seeking  new innovative structures of schools of thought that are geared towards Complexity Science and Complexity Thinking.

II, Complexity Science School of Thought

Complexity, Emergence, and Feedback

Complex Systems - Definition

A complex system is composed of many interacting agents in which the emergent outcome of the system is a product of the interactions between the agents and the feedbacks between emergent outcomes and individual decisions of agents.

Agents - Definition

An individual that exhibits the capacity to achieve a goal or to effect an outcome. Often the term "agent" implies that an agent operates within a population and interacts with other agents as well as with a more passive environment.

Emergence - Definition

Emergence is the idea that the action of the whole is more than the sum of the parts (John Holland, 2014). The interaction of agents produce emerging outcomes. Emergent outcomes may be patterns or trends that are predictable, but in many cases, the underlying variables associated with each agent's behavior, properties and changes in the environment in which the system under study operates, many produce unpredicted outcomes.

Feedback - Definition

Feedback loops describe a relationship within a system where events feedback on themselves to create relationships of interdependence where different events work to balance each other or amplify each other. Feedback loops are central to the dynamics of nonlinear systems of all kind, from financial crisis to population growth, to ecosystem collapse to the outbreak of conflict; they are the engines of self-organization, being what drives the process as it develops over time. The are two types of feedback, positive feedback, and negative feedback. Positive feedback loops work to accelerate change while negative feedback, works to dampen down change, constraining the system towards a stable state. Positive feedback loops can be a powerful force that if left unchecked will take the system out of its current overall state and into a phase transition as it moves into a new regime.


Next week I'll post information about tools that will help us work with the Complexity Science School of thought and provide examples of related applications with some projects I'm currently working with.

Nilza Cruz
939-644-7683

Dear All: Yes...WE Can!

Nilza I. Cruz Ruiz

May 29, 2017

The overall circumstances and unique social, cultural and economic situations we’ve been facing in Puerto Rico have served as motivation for sharing my story.

New York, New York

In June 1966, I began my physical journey into this world born in the Jacobi Hospital located in the Bronx, NY to my beloved parents Manuel and Carmen. Both, Puerto Rican immigrants who moved to New York in the quest for the American Dream. I have an elder sibling, Manuel Jr. Dad, a hard-working butcher who worked mainly at racetrack restaurants and mom, a housewife. Neither completed high school before migrating to the big apple. They spoke very little English. We lived in the Bronx, at 525 Rosedale Ave. Apt. 1G. It was a two (2) room apartment one (1) bathroom, small living room and very tight kitchen/diner. My brother and I shared one bedroom. This was part of a housing project (like the caseríos in PR) surrounded by “bodegas”, people who would call us “fucking Porto Ricans” each time the saw us, and other nicer folks. I was never allowed to go out and “play” unless accompanied by one of my parents; oh, and because I was a girl and “girls were never to be left alone”. I wasn’t even allowed to go to a baseball game with dad and my brother just for being a girl!

With much sacrifices, they (my parents) sent my brother and myself a couple of years to Holy Cross, a catholic school in the Bronx. I loved the school. I remember my teachers were “Brothers”, “Sisters” and a faculty composed mainly of Jewish, Polish and/or Italian backgrounds. This intrigued me. I loved the fact that my gym teacher was “Brother Frank” (with the long brown cloak), my math teacher was “Sister Christopher Joseph” (a nun), and my math teacher was not a nun, but Polish, and very “smart”; at least, from my perspective.  For another couple of years, when Dad couldn’t afford Holy Cross, my brother and I attended PS 169, a public-school right across the street from our previous one. It was hard, but we had to adapt, the hard way; either do it, or do it! But not going to school was NOT an option.

Our daily journey to school was a fifteen (15) minute daily walk in the morning, and in the afternoon. Mom would always walk us! I loved to learn, discover, and be creative. I remember asking so many questions. All related to the why, how, when where, etc. I was a daydreamer. This was my nature. Many times, transposing concepts or the abstracts I thought about or created about certain conceptions; (many of them math or science related), into new “things” I could discover, “see” and just continue to think about.  Then the intersections of what I could “see” with experiences in my daily life, and other concepts I either read or was introduced to in school, or simply by the owner of the nearest bodega; Mr. Abelardo. I loved this feeling, and oh, I was very insistent in understanding. How? I would always read, understand, and draw what I read and understood, and then connected with the existing and other logical concepts. Then I looked at myself in the mirror and I would narrate what I understood, looking for my own approval and meeting of my own mind with that of the author’s. It was a kind of game; the game of understanding which required a hell of a lot of perseverance.

At home, it was both my parents, and my parent’s family and friends in New York, speaking Spanish all the time. As for the music, it was Willie Colon, La Fania, Hector Lavoe and salsa all the way. It was an exquisite menu of rice and beans, fried eggs, corned beef, salami, Italian bread (which I loved), and especially for dad, Colt 45, Budweiser or Schaeffer. During the weekends, I would bring beer to my dad, open them, and of course, grab a sip! It was cold as hell during the winter and dry hot during the summer, my favorite part of the year. We would visit Orchard Beach with a pot of rice, cheese puffs, beer, and a blanket for the family. And oh, the Puerto Rican parade. That was it! I could understand Spanish, but hardly speak it.

Off to “Porto Rico”

Spring 1976. For reasons I have to be frank about and confess I still do not entirely understand, mom decided my brother and myself would re-locate or move with HER to Puerto Rico. She said the island was beautiful and we would live a much better life in a beautiful “private home”, different from the projects we were living at. She would also tell us about the “flamboyanes” and beautiful beaches. So off we were to the island in July 1976. We arrived at Puerto Rico to the town (county, if you will) of Cabo Rojo. In Cabo Rojo, we lived in a neighborhood (“barrio”) named “Parabueyon”, a rural area with a lot of sugar cane and dirt streets.  A small town located at the south west part of the island and minutes away from beautiful beaches. We moved in with mom’s father (elderly 78 year old-“Jovino”, whom my brother and I never met), and her youngest brother, my uncle “Tato”.  The house, a three room wooden home with a zinc roof. The side wood had quite a few holes, and the floor was also wooden with many holes as well.  The foundation of the wooden house was composed of a few wooden plinths (zócalos) embedded in clay. It was full of bugs and during the evenings, bats and giant cockroaches would make frequent visits. This pretty much framed the beginning our new environment. Mom, my brother and I slept in the same bed which mattress was terribly uncomfortable. At the time, I was 11 and very upset. It was soon to be August and on the island school would begin in this month.

So off we went to Saint Augustine School in Cabo Rojo. Even though mom didn’t have a job, she relied on the fact that dad would send her enough money to make monthly payments for my brother and I catholic school tuition. Off we went.  We began in our new school. I didn’t speak the language, I lived in a very poor home in a very poor “barrio” and here I was in a private school commencing my 6^th grade. But of course, the kids at school named me “la jÍbara muda de parabueyon” (the country mute girl from the “hood”). I didn’t even understand what this meant, but I remember the deceptive laughs and making fun of me. There was a lot going on. The radical environment change, the school, the mean kids, and the economic limits. You see, many years later I learned dad was either unemployed or employed with less income, and it was extremely hard for him to keep us with private school payments, food, etc. Oh, and mom didn’t work. Shortly after, mom was on welfare. She received food stamps and health benefits from the Puerto Rico Commonwealth.  I clearly recall one day I went with her to the supermarket for groceries. In a particular aisle, I spotted a “Cosmopolitan” magazine with an executive image of a woman on the cover. I immediately said to myself, “I don’t know how, but I am going to be an executive”. Even though mom was receiving assistance from the government, I was just not happy with the feeling of dependence. I felt embarrassed.

Mom defaulted at our school payments. With luck, my brother received a sports scholarship at Saint Augustine and even though I was also in the volleyball team, (yes me), the scholarship was just for one; my brother. So mom continued defaulting on my payments and there were many times I was scolded by school administration in front of my classmates because my mom didn’t pay. At home, it was eating whenever there was food depending on food stamps, grabbing mangos and coconuts from nearby trees, and supporting the most terrible menstrual pains with no medication what so ever. Mom just said: “there’s no medicine, take the pain”. Tough for a teen!  But there’s something I could tell you, this was reality. And it was up to myself to be / or not, whatever it was I wanted to become in the future. Of course, there were days with no food, embarrassments, no money, bugs, bats, cockroaches and a lot of fear. Mom did what she could. Dad, also. It was NOT their fault.  I had a great cousin who was kind enough to help me in my Spanish, and in school, I focused on getting good grades (studying twice or maybe triple as hard because lectures were in Spanish), and in volleyball. Boy did that volleyball help me focus. The sport exploited my competitive side and shielded my poverty. I felt like the “Queen of el Barrio Parabueyon”.  I always wanted to help and lead. I was president of my class at the 11^th grade and fought for equality amongst my classmates. I almost got expelled from grade 11 for not agreeing with naming a student who was included as member of the National Honor Society with a GPA of 2.50 , but his parents were very generous in $ contributions to the school. Of course, I was punished with not being part of the Honor Society myself at senior year with a 3.55 GPA and complied with all requirements. Also, I was demoted to VP of my class. What was new? I did get the message across!

After so much adversity, I managed to graduate thanks to Sister Anne Eugene, school director at the time, who pardoned my mother’s tuition debt with the school and my “faulty” actions with the National Honor Society kid incident. She understood I was a leader and she believed I would someday be very successful. Thanks Sister Anne!!!

I applied to the University of Puerto Rico, Mayaguez Campus. I wanted to study Pure Mathematics just because I loved math, it satisfied my intellectual challenges, and I understood it could help me establish a frame of mind or thought for my ongoing curiosity of things and inquisitive thoughts, imagination, and creativity. I was accepted!!! So in August, 1984 I began my undergraduate studies. I would rely on public transportation, the food stamps mom continued receiving, state health program, the federal Pell grant, and a part time job at Almacenes Rodriguez (shore & purse store) at the Mayaguez Mall as a cashier for the next four (4) years. To make ends meet, I learned how to sew my own clothes (using an old Singer sewing machine Dad sent me from New York) to go to work at the Mall.  I didn’t sleep at least 3 out of 7 days a week. I helped support mom as well. There were times I cried and cried, because sometimes it seemed impossible, but I graduated from Pure Mathematics with a minor in Statistics in May, 1989, even though I completed required undergrad credits in December 1988. In May, 1989, I received a job offer from the NSA, which I refused just to stay in PR and support mom. I know, it was a tough decision, which I don’t regret! In enrolled in graduate school of the Mayaguez Campus to pursue my MS in applied statistics in August, 1989. During this time, I was a TA at the Mayaguez undergrad school of mathematics. At the same time, I taught Geometry and Pre-Calculus at a private high school at Mayaguez. It was a nice experience, up until the director of the school instructed me to change a student’s grade from 81% to 91% in Geometry because the student wanted to pursue studies in engineering in the US and 81% in Geometry (what was earned) wouldn’t help much. This was a huge deception for me yet a great experience; of life. I denied the petition and handed my letter of resignation effective immediately. This was totally against my work ethics; and most important; to my understanding, this action would not help this student.

Bull’s Eye

By 1991, I was convinced I wanted to move from the southwest part of the island  to the capital of Puerto Rico. A place I had only visited once: San Juan. My brother’s mother n’ law sent me a newspaper add which stated that the Office of the Commissioner of Insurance in San Juan was seeking for an ”Auxiliary Actuary”. So I went for it. I embraced a three hour ride from Cabo Rojo to San Juan in my 1979 Omega which lacked air conditioning. And there it was! I got the job which would pay me (net) $630.00 a month. This, for rent, food, gas, etc. But from this point on, I entered the insurance industry as Underwriting Trainee, Commercial Lines Underwriter, Quality Administrator, and at 30 years, I was Vice President at a Multinational Insurance Company. Excellent pay, benefits, Banker’s Club privileges, great office, parking, golf. Oh, and in the Financial District of PR in San Juan! Bull’s eye!! I was finally the executive woman I had pictured back in 1981! In parallel, I completed an MBA and graduate certification in the Insurance Institute of Philadelphia and the College of Insurance in New York.  Not to mention my traveling to home office in Miami and great worldwide learning experiences!

It’s not as beautiful as expressed. There were lessons learned the hard way. Components related with internal politics, rules and regulations, culture, and behavior are embedded within performance and results obtained conformed great part of said lessons. Within these organizational frames of work, said components, especially rules and regulations, are meant to be followed. All eyes are on our performance, which means we are not only perceived as the results we obtain, but how are we as leaders, as a function of how well we can “navigate” within the organizational landscapes, and internal politics play a critical role in this navigation quest. What is fair for us may be perceived in a different manner by others, in an intentional or non-intentional manner. It all depends… as a professor, mentor and someone very close whom I’ve learned very much from, has taught me.

I learned that even though I was trained as a scientist, we need not always communicate as scientists, subject to who our audience is. We need to understand and accept that social and cultural components should always be considered in studies we conduct. Also, the art of negotiations. Obtaining balances, and carefully identifying and understanding tradeoffs; from all sides.

But as of today, I am part of the big picture: PUERTO RICO. I am continuously conducting research and studies with a group of associates geared towards the interrelations of mathematics, statistics, physics, finance, social sciences, arts, law and economy with the development of organizational landscapes that would promote higher levels of efficiency within government and private ecosystems. In particular, health and academic systems.

Time to Move On

Time passed and I had two beautiful kids. Sofi, almost 19, and Jean, soon to be 17. After a second Vice President position in another Multinational Insurance Company, I was self-employed for many years. During 2011 and 2012, I worked directly with a special musical project at the PR Conservatory of Music, geared towards providing needy children in PR the opportunity of discovering and expressing their creativity by playing an instrument and forming part of an orchestra. This would also provide them discipline. It was in December 2012 that I was invited to join the management team of the Puerto Rico Medical Services Administration. At first, awkward. But after much thought, I was born in a public hospital in New York, and I was raised under the Puerto Rico’s public health system; at the time; Arbona System. Why not try public service within the public system I myself grew up in? Of course, now the Model was based on the Health Reform System, not Arbona, but why not contribute to make it better? This was my frame of mind and I accepted. But thinking about the job and accepting is one thing, but being part of the system, I mean, is another. Talking with patients and families receiving health services in the emergency room, outpatient clinics, and other facilities within the medical center make you really UNDERSTAND that there are people in need, and expect much from public service employees. We need to continue to be their role models, and continue to research and study alternate and more efficient methods from which they, the people of Puerto Rico, the private sector and all components which constitute our island’s macro-economy can benefit. We need to step up as leaders and be more creative. We need to continually research and study, no matter our age!! Education and leadership are key. We need to promote these qualities we all have in a NON POLITICAL MATTER. As Former Medical Service Administrator, I gained knowledge to understand how I can contribute to make Puerto Rico in a better place towards achieving all goals, macroeconomic, financial, organizational, cultural, and behavioral.

This is what I’m focused on along with an exceptional group of professionals. Another thing, we cannot work alone. We are responsible for assembling networks that will help us achieve our endeavors.

I barely slept or ate for a long time, but it wasn’t impossible. As part of our system, there are rules to follow. Following them or not will always generate causal loop feedbacks, but we have to increase levels of perseverance, be wise and obtain balances within everything we work on or achieve.  Let’s be open to dimensions we have not seen, but are very close to us.  We see because we promote ourselves to “seeing”, outside of existing models or frames of work.  Where we are today, or where we’ll be tomorrow, depends on us, and where our minds and creativity position us, along with the intersections we promote with groups of people and other components associated with our islands economic, organizational, fiscal, and social landscapes.

 I say, Yes…We Can!

To our students…… let’s be instruments of change, in a balanced and well thought manner!