Year in review: HCA Healthcare’s top 10 stories of 2022
The year 2022 signaled a gradual return to normal after more than two years of a pandemic. Long dominated by COVID-19, national health headlines revealed new emerging public health challenges in 2022: an unprecedented mental health crisis, the opioid epidemic and the rise and return of other infectious diseases including respiratory syncytial virus (RSV), influenza, polio and monkeypox. Through it all, HCA Healthcare’s more than 283,000 colleagues have shown resilience and discovered new and innovative ways to address these challenges together, grounded in our mission to care for and improve human life.
After reviewing the thousands of stories from across HCA Healthcare, we identified the articles and stories that captured the interest of our readers. From partnerships to advancing health equity in communities across the United States to nurses that cared for their patients like family – read below as we spotlight the top 10 HCA Healthcare stories of 2022.
1. Expanding access to education amid national nurse and physician shortages
The nation’s national nursing and physician shortage has been exacerbated by the COVID-19 pandemic. HCA Healthcare announced new educational initiatives in 2022, designed to train a strong pipeline of clinicians that will serve patients in hospitals, surgery centers, freestanding ERs, urgent care centers, diagnostic and imaging centers, walk-in clinics and physician clinics. Learn about our 2022 investments to nurture a pipeline of clinicians critical to healthcare in our communities:
(January 2022) The HCA Healthcare Foundation, through its Healthier Tomorrow Fund, announced that it will donate $1.35 million over three years to Educate Texas, an initiative of Communities Foundation of Texas. The grant is aimed at increasing student access to programs that enable healthcare careers, including high schools in Texas that offer Pathways in Technology Early College High School (P-TECH) healthcare career tracks.
(March 2022) HCA Healthcare offered 1,867 positions for its July 2022 graduate medical education (GME) programs on Match Day, March 18. We began building a network of GME training programs eight years ago and it has since become the largest sponsor of GME training in the United States. In addition to training more residents and fellows, we’ve expanded our training to 337 Accreditation Council for Graduate Medical Education (ACGME) accredited programs, 5,334 residents and fellows and 62 teaching hospitals across 16 states.
(April 2022) On April 26, HCA Healthcare announced a $1.5 million donation to Florida International University’s (FIU) Nicole Wertheim College of Nursing & Health Sciences (NWCNHS) to expand its faculty and offer scholarships to increase enrollment and help address the national nursing shortage. The partnership is one of four that HCA Healthcare announced this year as part of our organization’s commitment to donate $10 million over three years to Historically Black Colleges and Universities (HBCUs) and Hispanic Serving Institutions (HSIs) in order to advance diversity in healthcare.
(June 2022) On June 13, HCA Healthcare announced plans to open a new Galen College of Nursing campus in Asheville, North Carolina, as part of our commitment to educate a growing number of future nurses amid a national shortage.
The Asheville campus, which opened in December 2022, is the eighth new campus that Galen College of Nursing has opened since joining HCA Healthcare in January 2020. At the time, Galen offered nursing programs across five campus locations, as well as an online campus, and had a total enrollment of approximately 7,100. With the Asheville campus open, Galen College of Nursing now has 14 campus locations and enrollment was projected to reach approximately 10,000 in 2022.
Galen College of Nursing has instructional campuses in several states where HCA Healthcare has a presence, including Florida, North Carolina, South Carolina, Tennessee, Texas and Virginia.
(July 2022) As part of HCA Healthcare’s $10 million commitment over three years to HBCUs and HSIs, HCA Healthcare announced a $750,000 donation to The University of Texas at El Paso (UTEP) to create multiple graduate-degree opportunities for students interested in healthcare careers. The four-year partnership – with one of the largest Hispanic-serving institutions in the country – will support more than 30 nursing fellows and more than 50 healthcare administration opportunities. The gift will help establish graduate nursing fellowships and create a graduate degree to advance healthcare administration.
(October 2022) In October, HCA Healthcare announced two large donations to HBCUs in Middle Tennessee, including a $1.5 million donation to Tennessee State University (TSU) to fund scholarships for undergraduate and graduate students pursuing careers in healthcare and computer science. Funds from this gift will support scholarships for students participating in the university’s Dr. Levi Watkins, Jr. Institute Accelerated Medical Pathway program. Three two-year scholarships for rising juniors and three two-year scholarships for graduate students within the College of Engineering will also be awarded.
The following week, HCA Healthcare announced a $1.5 million donation to Fisk University to support scholarships for students pursuing a degree in nursing. The gift will provide scholarships over four years for Fisk health science and nursing students interested in pursuing the Bachelor of Science in Nursing (BSN) program at Galen College of Nursing. This new investment from HCA Healthcare is designed to help support students in the nursing pathway by providing hands-on shadowing opportunities, mentors, seminars, leadership sessions and career guidance to scholars. The gift will also help support the implementation of the program by funding additional faculty support at Fisk.
HCA Healthcare has now announced approximately $6.75 million to multiple colleges and universities towards our $10 million commitment to advancing diversity in healthcare.
2. Natural disaster emergency operations and community relief
Disaster response exercises are how our HCA Healthcare family stays prepared to care for our community and colleagues even in the most difficult times. The year brought wildfires, tornadoes, flooding and storm events to our communities. During times of emergency and large-scale disasters, HCA Healthcare stood ready to respond and lend support.
(July 2022) In late July, floodwaters rushed through 13 counties in eastern Kentucky, destroying bridges and homes, resulting in at least 38 deaths and leaving communities without electricity, water and roadway infrastructure.
HCA Healthcare’s Galen College of Nursing, a leading educator of nurses in the United States, has a campus in Perry County, one of the counties hit by the flooding. As many of the college’s nursing students, faculty and staff live in and around the impacted areas, HCA Healthcare took steps to assist those affected by the devastation. In early August, HCA Healthcare announced that it would contribute up to $400,000 in funding, colleague matching and in-kind donations to support organizations providing relief services to eastern Kentucky communities struck by this historic flooding.
(September 2022) On Wednesday, September 28, Hurricane Ian made landfall on the west coast of Florida as a powerful Category 4 storm with maximum sustained winds of 150 miles per hour. The widespread destruction left more than 2 million people without power. HCA Healthcare operates 49 hospital campuses and has approximately 77,000 colleagues in the state of Florida, many of whom were affected by the hurricane.
Once the hurricane passed through our communities, HCA Healthcare was quick to set up on-site mini-marts, fuel stations, showers and laundry services in Florida to assist facilities, colleagues and nearby health systems in need. Additional support was also available to colleagues through the HCA Healthcare Hope Fund, an employee-run, employee-supported 501(c)(3) charity that provides financial aid and resources to employees after an extended illness, injury, disaster or other special situation.
HCA Healthcare also committed to contributing up to $1.5 million through community organizations and colleague matching to aid relief efforts in Florida including:
- $1 million to the Governor’s Florida Disaster Fund
- $250,000 to the American Red Cross
- Up to $250,000 in colleague matching gifts to the American Red Cross.
3. Forging new partnerships to improve health equity
As part of our continued dedication to providing equitable access to care, HCA Healthcare formed the Health Equity Council in January 2021 to help identify and address health disparities within and outside of our hospitals, as well as to develop strategies that advance health equity. This cross-functional group of senior leaders — co-led by our chief clinical officer and chief diversity officer — analyzes race, ethnicity and language (REaL) data, sexual orientation and gender identity (SOGI) data and other socio-demographic characteristics to address disparities and improve patient quality, safety and satisfaction outcomes for diverse populations.
The findings from our annual equitable outcomes analysis have been used to shape the focus of initiatives undertaken by the council, including partnerships with community organizations and industry partners to address specific opportunities related to cardiovascular health, cancer screenings and navigation services, and maternal health for communities of color. Health equity-focused partnerships in the news in 2022 included:
(August 2022) A new collaboration with Johnson & Johnson was announced in August to address key healthcare industry issues initially focused on improving health equity, enhancing nursing support and improving patient outcomes:
- HCA Healthcare and Johnson & Johnson will collaborate on a scalable program to improve health outcomes through early-stage lung cancer detection for the Black community. Lung cancer is the number one cause of cancer death among Black patients, and the two companies will begin to work together on a pilot program in the coming months to increase early identification.
- HCA Healthcare, which has more than 93,000 nurses in our system, and Johnson & Johnson have a long-standing commitment to advocating for and supporting nurses. We will work together to incorporate Johnson & Johnson’s nursing resources within HCA Healthcare and affiliate Galen College of Nursing. The companies will also work together on health equity issues focused on educational programming, training and other programs that elevate and support nurses with a goal of enriching the nursing experience and skillsets and improving patient outcomes.
- HCA Healthcare, through its HCA Healthcare Research Institute, and Johnson & Johnson will collaborate on cardiovascular health initiatives including a retrospective analysis of patients who suffer from heart arrhythmia, as well as research to understand the role digital health technology plays in impacting clinical outcomes for patients with Coronary Artery Disease (CAD) and Peripheral Artery Disease (PAD) diseases.
(October 2022) The American Heart Association debuted their Getting to the Heart of Stroke™ initiative, developed in conjunction with and supported through $15 million in total funding from HCA Healthcare and the HCA Healthcare Foundation. The initiative focuses on preventing, treating and beating stroke by providing consumer and healthcare professional education nationwide, deepening collaboration between neurology and cardiology and equitably empowering communities about stroke risk to improve health outcomes.
Knowledge and management of heart-related risk factors and conditions are critical in reducing the likelihood of and improving outcomes with stroke, especially across populations with health disparities. This powerful connection between heart and brain health is the target of a new initiative focused on clinical training, community and patient education, as well as diagnosis and treatment.
As part of the new initiative, American Heart Association staff and volunteer experts, with support from the HCA Healthcare Foundation and HCA Healthcare community colleagues, will work in 15 select communities to implement community education. The nationwide initiative will also focus on stroke risk factor awareness and professional education projected through the lens of equitable health for all.
HCA Healthcare is the largest system for delivering babies in the country and more than 217,000 babies are delivered at our hospitals every year. In 2022, HCA Healthcare continued to deepen our longstanding relationship with March of Dimes by focusing on improving maternal mortality and morbidity outcomes through postpartum discharge education and by lowering hospital caesarian rates among low-risk, first-time mothers, head first position or NTSV (Nulliparous, Term, Singleton Vertex) rates. Together, March of Dimes and HCA Healthcare are using our clinical data, pioneering research and passionate history to deliver healthier tomorrows for mothers and babies.
In 2022, our HCA Healthcare family participated virtually and in-person in March for Babies: A Mother of a Movement™, an awareness and fundraising campaign aimed to support every family throughout their pregnancy journey and raise critical funds to help March of Dimes provide research, programs, education and advocacy, so moms and babies get the best possible start.
4. Integration and scale connect patients with convenient care
(March 2022) On March 3, more than 450 HCA Florida Healthcare-affiliated sites of care across the state united under a shared brand for the first time. This transformation created a leading collaborative healthcare network in the state, united through a shared dedication to improve more lives in more ways.
HCA Florida Healthcare connects approximately 11,000 physicians and 77,000 colleagues serving their communities at 49 hospital campuses, more than 350 physician practices and freestanding emergency rooms and more than 50 urgent care centers.
Earlier in 2022, HCA Healthcare Florida added MD Now Urgent Care, enhancing our already strong capabilities in a rapidly growing state by providing convenient outpatient care options for our patients. The move also connects MD Now patients to a comprehensive statewide network of care, including acute care and specialty services should they be needed.” MD Now Urgent Care is a network of 59 urgent care centers in Florida.
(May 2022) An HCA Healthcare Florida COVID-19 patient was featured in the Federation of American Hospitals’ new campaign: The Real Story. The campaign aims to highlight the critical work hospitals do every day to support frontline caregivers and care for patients. Rachel Watson’s powerful patient testimonial showed how hospital integration improves the care hospitals can provide through better coordination and increased access to advanced medical technology. Rachel credits the integrated, high level of care she received from the dedicated staff at HCA Florida Healthcare with saving her life.
When Rachel’s breathing became labored, her husband called 9-1-1. Paramedics rushed Rachel to HCA Florida West Marion Hospital where caregivers put her on an oxygen machine. Unfortunately, it wasn’t enough. Rachel required more intensive care and the decision was made – she needed to be put on an Extracorporeal Membrane Oxygenation (ECMO) machine. Her care team was able to seamlessly transfer her to a sister facility, HCA Florida North Florida Hospital in Gainesville, where she was placed on ECMO and her care continued.
One HCA Healthcare nurse put a battery-operated heart lamp in Rachel’s hospital room window each night so her husbands and sons would know exactly where she was so they could pray underneath her window. And even though she was unconscious, nurses took an iPad into Rachel’s room every night so her family could talk to her via FaceTime.
Today, Rachel is back to her active life, with just a few lingering effects from her arduous experience. Watch Rachel’s real story below:
5. Addressing mental health needs of our communities
In 2022, HCA Healthcare furthered our commitment to addressing the growing need for mental health awareness and education. We announced partnerships with leading community organizations to combat the current mental health crisis impacting communities nationwide.
(May 2022) The HCA Healthcare Foundation announced a $1.38 million donation over the next three years to Girls Scouts of the USA to start work on creating a series of workshops aimed at addressing better mental wellness among girls. The curriculum strives to help girls better understand mental wellness and provide them with the skills to strengthen their resilience and support their peers.
In collaboration with National Alliance on Mental Illness, the HCA Healthcare Foundation’s grant will support Girl Scouts’ Mental Health 101 workshops, consisting of Getting to Know Your Emotions for fourth through fifth graders, Finding Your Voice for sixth through eighth graders, and its Peer Support workshops for ninth through twelfth graders.
(August 2022) We announced a $600,000 grant to Volunteers of America (VOA) through the HCA Healthcare Foundation and its Healthier Tomorrow Fund to promote mental wellness and resilience among first responders. Through this contribution, VOA has scaled its VOA|ReST 4 First Responders program in targeted areas served by HCA Healthcare, such as HealthONE in Denver, Medical City Healthcare in Dallas-Fort Worth and HCA Florida Healthcare.
With the support of the Healthier Tomorrow grant, VOA has launched a national campaign and peer support service to help an expanded group of first responders – including fire, police, EMT personnel, hospital and emergency staff – process experiences of moral distress and burnout.
(December 2022) In December, HCA Healthcare and Musicians On Call (MOC) – a nonprofit that brings live and recorded music to the bedside of patients, families and caregivers in healthcare environments – announced a new collaboration to bring MOC’s live music programs to more hospitals across the country.
As part of the collaboration, HCA Healthcare is giving $1 million to fund the creation and launch of MOC’s propriety online platform designated to enhance its program delivery to enable the organization to reach more hospital patients and healthcare workers nationwide.
(December 2022) Psych Hub and HCA Healthcare, in collaboration with Columbia University’s Department of Psychiatry, partnered to bring a new 10-episode podcast series, “Coming Back Better,” to reflect on the lessons the pandemic taught us and what we can do to benefit our well-being. This series is following on the heels of our first podcast collaboration, “You Ask, We Answer,” which provides a forum for mental health education and encourages dialogue without stigma.
6. Donate life: leading the nation in live donor kidney transplants
The U.S. has reached a historic milestone this year: 1 million transplants. HCA Healthcare is proud to have contributed to the national milestone and to help provide the gift of life through transplant medicine at our transplant centers.
Procurement efforts have led to a greater percentage of living donor transplants, a key component in predicting long-term transplant success. Nationally, of the 18,799 kidney transplants in 2021, 24.2% involved living donors, while 75.8% were from deceased donors. Conversely, of HCA Healthcare’s 1,103 kidney transplants, close to 35% involved living donors, and 65% were from deceased donors.
(March 2022) Data from the United Network for Organ Sharing (UNOS) recognized HCA Healthcare affiliate Methodist Hospital Specialty and Transplant as the nation’s only transplant program in history to perform more than 200 living donor and more than 200 deceased donor kidney transplants in a single year.
With the groundbreaking work at Methodist Specialty and Transplant Hospital in San Antonio setting the pace, HCA Healthcare has emerged as a leader in providing access to kidney transplants to the country’s Hispanic/Latinx population. More importantly, of those 1,103 transplants at HCA Healthcare facilities involving a living donor kidney transplant, 15.96% (176) were Hispanic/Latinx patients, compared to 4.14% nationally. That’s a significant difference, given the superior outcomes of kidney transplants with a living donor.
(June 2022) For Father’s Day weekend, HCA Healthcare patient Jason James received the best gift anyone could ask for – the gift of life from his son. Jason was diagnosed with polycystic kidney disease, a genetic disorder that causes cysts to grow in the kidneys. “I started dialysis last year in August because my kidney function, in terms of percentage filtration, went down to four percent,” said Jason. That’s when his 23-year-old son volunteered to become a kidney donor for his dad.
“It was never really a question of if I would do it,” said Michael Evans, who’s going to medical school in the fall. “It was just how can we move forward.” After the initial testing, Michael was approved to become a kidney donor and physicians at HCA Florida Largo Hospital’s Transplant Center performed a successful surgery. The story was featured on ABC News’ World News Tonight.
(July 2022) In June, the transplant team at HCA Healthcare affiliate St. David’s North Austin Medical Center also became a part of history. Their transplant team performed the first living kidney donor surgery through the National Donate Life Living Donor Registry. HCA Healthcare patient Camden Underwood was a non-directed living donor, meaning the kidney was given anonymously to an individual on the list for a kidney transplant.
This year, Donate Life America, the nonprofit organization that registers organ donors and works to spread the word about organ donation, added a new option to its registration online. In addition to registering to become an organ donor in death, it asks you if you’d like to become a living kidney donor. The program is currently being tested in Texas but could expand to other states in the new year. Texas was chosen as the pilot state because there are more than 20 organ transplant centers, including St. David’s North Austin Medical Center and Methodist Hospital Specialty and Transplant.
“We are proud to work with Donate Life America to make living kidney donation more accessible. A living donor kidney is the gold standard of kidney transplants. A living donor kidney is lifesaving. It is a lower risk procedure compared to a deceased donor transplant since the living donor kidney is more likely to be successful in the recipient,” said Dr. Jacqueline Lappin, surgical director of the Kidney Transplant Center at St. David’s North Austin Medical Center. “This new registry will help increase the availability of kidneys with more life-giving quality for patients who need one.”
7. Emergency room nurse goes the extra mile for cancer patient
(May 2022) HCA Healthcare nurse Matt Paveglio serves our patients in the emergency room at Alaska Regional Hospital in Anchorage, Alaska. Through the challenges of the pandemic, he’s relied on 20 sled dogs, his mother’s legacy and the resilience of a pediatric cancer patient to help him compete as a rookie in the 2022 running of the “Last Great Race on Earth” – The Iditarod.
After witnessing the COVID-19 frontlines inside the ER, Matt says being able to get outdoors and connect with nature has been good for the soul. “Nothing is harder in my opinion than nursing in a global pandemic. I realize more now that we need to make the most of our moments and the Iditarod is the opportunity for me to live that spirit,” Matt said. “Mushing makes me feel more alive than ever!” And, he’s not the only one who’s benefitted from the Iditarod.
When 10-year-old patient, Lauren, embarked on a race against ovarian cancer, she met Matt at Alaska Regional Hospital. After Matt found out that Lauren was an autistic patient, he used conversations about dogs and sled racing to keep her calm – especially when he placed an IV and prepared Lauren to receive X-rays and a CT scan. His heart quickly attached to this family as he has a daughter Lauren’s age. They bonded over the courageous dogs, and Matt even gathered Lauren a team of 50 stuffed huskies so she could have her own Iditarod team.
When the Iditarod kicked off in March, Lauren surprised Matt at the ceremonial race start with two of those husky stuffed animals to take with him on the trail.
The same year Lauren was diagnosed with ovarian cancer, Matt’s mother also received the same diagnosis. She passed away in August 2021. She, too, was a nurse who dedicated her life to healing others. Matt’s mother was one of his biggest supporters in both his nursing career and mushing endeavors. To honor her during the race, he stopped to spread her ashes. “In my bag, I had my mother’s ashes and I had Lauren’s dog. So, I had these two women with me to push me along the trail and motivate me,” Matt told Good Morning America.
Not only did he participate in “The Last Great Race on Earth” in March 2022, but he completed the 1,049-mile race in eleven days and six hours.
8. Advancements in Care Transformation and Innovation
(July 2022) In July, HCA Healthcare’s Department of Care Transformation and Innovation (CT&I) celebrated its one-year anniversary. CT&I is a new department within our Clinical Services Group (CSG) designed to accelerate the integration of technology into patient care. Its vision involves clinicians, data and machine learning (ML) to explore innovations that will address problems in future healthcare delivery. CT&I brings together clinical staff, data science, engineering, technology, operations, change management and finance personnel, to “be boldly innovative and design the “future of patient-centered care.”
“We work elbow to elbow with frontline clinicians and hospital leaders to test, scale and measure solutions that make healthcare delivery more efficient and more effective by solving things that get in the way of delivering care,” said Dr. Michael Schlosser, HCA Healthcare senior vice president of Care Transformation and Innovation. “This gives clinicians and care teams more time to do what they do best, and patients more time communicating with care teams.”
With the debut of several initiatives at HCA Healthcare’s Innovation Hub hospitals and Innovation Departments, the CT&I team kept busy in 2022. They focused on launching the Staff Scheduler pilot, which uses algorithms to predict staffing needs, measure the complexity of different procedures, and optimize staffing according to nurses’ proficiencies and schedule preferences. The goal is to have the right staff members in the right places, at the right time, to deliver the best care possible for patients. “Since we began to pilot Staff Scheduler, we’re already seeing significant time savings, improvements in nurse satisfaction and, importantly, optimized staffing to meet patient demand and needs,” Dr. Schlosser said.
Another 2022 area of focus for the CT&I team included enhancing clinical documentation processes through change management, automation and technology – including a smart eyewear pilot at HCA Healthcare’s UCF Lake Nona Hospital that uses AI to listen and process clinician/patient conversations, and turn them into a document, like a transcript.
9. Father-son doctor duo serve patients together in Virginia
(June 2022) HCA Virginia Healthcare physicians Dr. David Randolph Sr. and Dr. David Randolph II made a special Father’s Day appearance on the Kelly Clarkson show in Jun 2022e to shed light on how they “care like family” together. The father-son duo both treat cancer patients as radiation oncologists at Sarah Cannon Cancer Network at Chippenham & Johnston-Willis Hospitals.
While on the former American Idol winner’s talk show, they shared what it’s like working side-by-side in the same office, and Dr. David Sr. reflected on his inspiring journey to become one of the first Black radiation oncologists in the country. Drs. Randolph I and II both hold patient care at the core of their work, ensuring that their patients feel taken care of first and foremost, partially due to their own experiences of supporting loved ones through cancer experiences.
“My dad has always been my hero,” says David Randolph II. “A lot of people have pictures of sports heroes on the wall – and, I literally to this day – have a little photo of my dad when he was in medical school which has served as my motivation.”
10. HCA Healthcare volunteer reunites with birth mom, discovers they work at same Utah hospital
(May 2022) The story of Benjamin Hulleberg, his adoptive mother and biological mother, went viral in 2022 and gave hope to many across the country. After two decades of wondering and searching, the HCA Healthcare NICU volunteer recently reunited with his birth mother after receiving a Facebook message from her. Benjamin’s mother? HCA Healthcare colleague Holly Shearer, a medical assistant at The Heart Center at St. Mark’s Hospital in Salt Lake City – where she and Benjamin have both worked for the past two years, unbeknownst to each other.
“Every morning, I would come through the Women’s Pavilion to come into work,” Holly told Good Morning America. “So, I passed right by the NICU every single day. We parked in the same garage, could have been on the same floor, having no idea that we were so close.”
Although it was a closed adoption, Benjamin grew up knowing he was adopted. He even knew that “Holly” was his birth mother’s name. “It was always a very positive conversation,” Benjamin said about the open dialogue surrounding adoption that existed in his home. “It was my parents either expressing gratitude for Holly or me talking about how I’m grateful to her and how I want to meet her one day.”
As we close the chapter on 2022, we thank all our readers and followers who were inspired by HCA Healthcare’s stories this past year. We look forward to highlighting the many ways HCA Healthcare cares for our patients, colleagues and communities in 2023! Be sure to follow along for more “good news” on HCA Healthcare’s LinkedIn, Facebook, Instagram and Twitter channels.
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About HCA Healthcare
HCA Healthcare, one of the nation's leading providers of healthcare services, is comprised of 182 hospitals and more than 2,300 sites of care, in 20 states and the United Kingdom. Our more than 283,000 colleagues are connected by a single purpose — to give patients healthier tomorrows.
As an enterprise, we recognize the significant responsibility we have as a leading healthcare provider within each of the communities we serve, as well as the opportunity we have to improve the lives of the patients for whom we are entrusted to care. Through the compassion, knowledge and skill of our caregivers, and our ability to leverage our scale and innovative capabilities, HCA Healthcare is in a unique position to play a leading role in the transformation of care.