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Nuka! South Central Foundation of Care
 

Nuka! South Central Foundation of Care

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In Alaska, ED and specialists visits dropped by half,hospitals stay days by 40%- with Nuka! A system focused on customer-owner care and open access

In Alaska, ED and specialists visits dropped by half,hospitals stay days by 40%- with Nuka! A system focused on customer-owner care and open access

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    Nuka! South Central Foundation of Care Nuka! South Central Foundation of Care Document Transcript

    • M20: Beyond Patient Centered Medical Home - SCF Nuka System of Care, Improved Overall Outcomes Katherine Gottlieb, MBA, DPS (h.c.), President/CEO Douglas Eby, MD, MPH, Vice President of Medical Services Presenters have nothing to disclose Copyright © 2011 Southcentral Foundation. All Rights Reserved. NOTICE: Unless otherwise indicated, this work represents copyrighted material protected by United States and international law. This work may not be used, reproduced, downloaded, disseminated, published, transferred or transmitted, in whole or in part, in any form or by any means, electronic or mechanical, including photocopying, recording or information storage and retrieval, except with the express written permission of the publisher. This work may not be edited, altered, or otherwise modified, in whole or in part, except with the express written permission of the publisher. Check In Powerful tool used to kick off dialogue Each participant in the dialogue has an opportunity to speak for a moment about what they are thinking or feeling while others listen in silence Time to “check into” the dialogue Use at beginning, end or a difficult times during a dialogue Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Check-in Introduce yourself at your table and discuss how you are doing today Discuss what are you hoping to learn today TIME – 10 minutes 3 Copyright © 2011 Southcentral Foundation. All Rights Reserved. Objectives Review the transformational journey of an entire healthcare system from physician centered to patient centered to customer-owned Understand the systematic approaches to creating and sustaining ongoing relationships between a customer-owner and physician that go beyond access and communication Understand the necessary requirements for moving beyond a patient centered medical home to a customer-owned healthcare system including the approach to: leadership, workforce, data, listening and responding to customers and the community, and healthcare delivery Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Katherine’s Story Copyright © 2011 Southcentral Foundation. All Rights Reserved. Check In Discuss how you connected with Katherine’s story and/or how did Katherine’s story impact you. Time: 10 minutes Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • The Importance of a Story Knowing one another in a deeper, more meaningful way, provides a richer, more meaningful work environment. Sharing stories helps create a place where there is value in relationship, where we value our customers Our stories are an important part of who we are (and who our co-workers and employees are) Copyright © 2011 Southcentral Foundation. All Rights Reserved. What is Story A record or narrative description of past events Sharing of story is done to show values, pass on skills, and in some instances show why and how something is or came to be Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Levels of Story A story can be shared at various levels or depths • 30,000 foot – i.e. What happened while you drove to work • 10,000 foot – i.e. A difficult situation getting along with coworkers or a friend • Ground Level or Below - i.e. A profound moment or memory that affects you today Copyright © 2011 Southcentral Foundation. All Rights Reserved. SCF Board of Directors Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Vision A Native Community that enjoys physical, mental, emotional and spiritual wellness Mission Working together with the Native Community to achieve wellness through health and related services Copyright © 2011 Southcentral Foundation. All Rights Reserved. Key Points Shared Responsibility Commitment to Quality Family Wellness Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Operational Principles Relationships between customer-owner, family and provider must be fostered and supported Emphasis on wellness of the whole person, family and community (physical, mental, emotional and spiritual wellness) Locations convenient for customer-owners with minimal stops to get all their needs addressed Access optimized and waiting times limited Together with the customer-owner as an active partner I ntentional whole-system design to maximize coordination and minimize duplication Outcome and process measures continuously evaluated and improved Not complicated but simple and easy to use S ervices financially sustainable and viable Hub of the system is the family I nterests of customer-owners drive the system to determine what we do and how we do it Population-based systems and services S ervices and systems build on the strengths of Alaska Native cultures Copyright © 2011 Southcentral Foundation. All Rights Reserved. Indian Self-Determination and Education Assistance Act 1975 Government recognized that: If the people receiving the health service are involved in the decision making processes, better yet, if they own their own health care – programs and services have a potential for enhancement and the people and their health statistics will improve. Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • At 591,000 square miles, Alaska is as wide as the lower 48 states and larger than Texas, California and Montana combined. Alaska San Francisco Charleston Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Customer Ownership 1982 - Fewer than 100 employees and budget of $3million 2013- 64,000 customer-owners; 1,600 employees; budget $227million Copyright © 2011 Southcentral Foundation. All Rights Reserved. From 1982 to 2013… Operating Budget $227m 64,000 Customerowners • 54,000 Anchorage and Valley • 10,000 55 villages Employees • 1982: Fewer than 100 • 2013: About 1,600 Operating Budget $3m 1982 FY 2013 • 1982: $3 million • FY 2013: $227 million Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • SCF Programs and Services Primary Care Dental Behavioral Health – Outpatient Behavioral Health - Residential OB-GYN Health Education Elder Program Co-manage 15 bed hospital (ANMC) Complementary Medicine Nilavena Subregional Clinic Radiology, Laboratory, Pharmacy Audiology Emergency Department Home Based Services Optometry Traditional Healing Family Wellness Warriors Infrastructure/Support Copyright © 2011 Southcentral Foundation. All Rights Reserved. Organizational Structures Office of the President • Divisional structure Executive and Tribal Services, Medical Services, Behavioral Health, Resource and Development and Organizational Development and Innovation • Line Authority Functional committee structure • 4 areas of focus to get to high performance Operations– effective day to day operations Quality Assurance– compliance with standards etc. Process Improvement– improving systems and structures Quality Improvement– improving clinical and educational services Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Why Listen to Our Story Copyright © 2011 Southcentral Foundation. All Rights Reserved. Measures of Success Utilization • 75% decrease in hospital admissions since 1999 • 71% decrease in hospital days per 1000 since 1999 • 36% decrease in outpatient visits per 1000 customerowners Clinical quality • Level 3 NCQA Patient Centered Medical Home • 75 or 90 percentile for HEDIS outcome measures o Diabetes o Cancer o Cardiovascular disease Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Measures of Success Customer-owner satisfaction • Overall 93% Employee satisfaction • Overall 94% • Response rate 83.2% Employee Turnover • 10.8% Baldrige National Quality Award - 2011 Copyright © 2011 Southcentral Foundation. All Rights Reserved. Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Doug’s Story: Copyright © 2011 Southcentral Foundation. All Rights Reserved. Check In Discuss how you connected with Doug’s story and/or how did Doug’s story impact you. Time: 10 minutes Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Primary Care needs changing Medical care is too big and too complex with way too many services, agencies, and offerings to be left uncoordinated and without a strong navigator/coordinator role Doctor-centric Medical Model primary care has failed – need to rethink everything Poor ‘primary care’ = ineffective system Current model actually does HARM Copyright © 2011 Southcentral Foundation. All Rights Reserved. Previous Healthcare Fixes - USA Limited capability if fundamental platform is not rethought • Think like a business, managed care, safety • Case Management 2002-2007 • Then – Six Sigma, TPS, flow, reliability, spread, bundling, P4P, E.H.R • Now - PCMH, ACO, Affordable care, single payer Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • PCMH Criteria The PCMH 2011 program’s six standards align with the core components of primary care • PCMH 1: Enhance access and continuity • PCMH 2: Identify and manage patient populations • PCMH 3: Plan and manage care • PCMH 4: Provide self-care support and community resources • PCMH 5: Track and coordinate care • PCMH 6: Measure and Improve performance The result of previous fixes Medical Model – not questioned Each piece of healthcare optimizing their financial position – very sophisticated financially and bankrupting society Better, faster, safer version of what we have – no fundamental change Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Who really makes the decisions? 100% “Control” 0 Low Acuity High 1. Control – who makes the final decision influencing outcome? 2. Influences – family, friends, co-workers, religion, values, money 3. Real opportunity to influence health costs/outcomes – influence on the choices made – behavioral change 4. Current model – tests, diagnosis, treatment (meds or procedures) Copyright © 2011 Southcentral Foundation. All Rights Reserved. Hitting the target… If you are in a mechanical, manufacturing environment then hitting a target it a matter of throwing a rock – figuring out speed, trajectory, etc. If you are in a messy, human, complex, adaptive environment – it is like throwing a bird at a target – it is all about the ‘attractor’ Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Hitting Target: Rock vs. Bird Copyright © 2011 Southcentral Foundation. All Rights Reserved. Some simple rules for improvement complexity diagram Certainty or Agreement Low Experimenting Get together and have dialogues Chaos An allowing/positive environment Complexity Multidimensional improvements with target focus Protocols High & Stds Low complexity variables Creativity High Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Reality Health is a longitudinal journey • Across decades • In a social, religious, family context • Highly influenced by values, beliefs, habits, and many ‘outside’ voices. Office visits are brief, reactive stop-gaps Hospitalizations are brief, intense interruptions MUST fix basic, underlying primary care platform first or nothing else will work well Copyright © 2011 Southcentral Foundation. All Rights Reserved. Purpose of Primary Care We are a Service Industry – NOT a product industry – coaching, teaching, partnering are central – pills and procedures supportive Changes what we think we do, who we hire, how we train, how we structure, how we reward, and how entire system is constructed as a system. We must optimize relationship – personal, trusting, accountable – minimize barriers Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Just Do It… Why not? Why not take the best known practices and design a system? Why not spread this system everywhere and reap the benefits? Why has this not already occurred? Why is this so hard? Copyright © 2011 Southcentral Foundation. All Rights Reserved. Difficulties Unquestioning belief in the medical model and professionalism Firm basis in science, technology, industrial manufacturing models, body as physical Many people making a whole lot of money in current system – as independent pieces Current system allows/supports/rewards independence and entrepreneurial thinking – no common purpose, framework, principles Very weak workforce and management theory, knowledge, skill in healthcare Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Copyright © 2011 Southcentral Foundation. All Rights Reserved. The Drive to Change Unfriendly and rude staff Guinea pig for new doctors Customers waited for everything • Long waits for scheduled appointments • Four- to six-hour waits common Long waits on phone, pharmacy, everywhere Inconsistent treatment Risky place to go Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Everyone Was Frustrated … Customers frustrated – waiting, impersonal, paternalistic, crowded, unfriendly Clinical staff frustrated – too many people, not enough time, no personal relationships, too many demands Management frustrated – lots of unhappy people, hard to motivate staff, poor financial performance, challenging facilities Copyright © 2011 Southcentral Foundation. All Rights Reserved. Check in Discuss what you would change in your healthcare system if you owned the healthcare system. Time: 10 minutes Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Customer-owner Southcentral Foundation uses the term customerowner instead of: • Patient • Client • Customer Copyright © 2011 Southcentral Foundation. All Rights Reserved. Questions Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Leadership - Key Improvements Our vision Shared Responsibility Operational Principles Core Concepts Board of Directors Role model National, regional and local partners Functional Committee Structure Copyright © 2011 Southcentral Foundation. All Rights Reserved. Leadership Development New Manager Orientation Self led, 90 day completion, includes meeting with CEO Leadership Readiness • Comprehensive (360’s, CDRs) Leadership Development Sessions • Facilitated by CEO day-long sessions Executive Leadership Experience Training Program Special Assistant Training Program Development Center Courses Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Core Concepts Three-day training, ALL employees Led by SCF President/CEO Build and sustain healthy relationships How we impact others How to articulate story from your heart Partnered with Society for Organizational Learning to develop Copyright © 2011 Southcentral Foundation. All Rights Reserved. Workforce Core Concepts - Key Improvements Work together in relationship to learn and grow E ncourage understanding L isten with an open mind L augh and enjoy humor throughout the day Notice the dignity and value of ourselves and others E ngage others with compassion S hare our stories and our hearts S trive to honor and respect ourselves and others Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Strategic Planning - Key Improvements Mission, Vision and Key Points Relationships across the organization Customer-owner input Copyright © 2011 Southcentral Foundation. All Rights Reserved. Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Linkages EVERYTHING TIES TOGETHER! Copyright © 2011 Southcentral Foundation. All Rights Reserved. SCF Strategic Planning Cycle Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Corporate Objective Example: Family Wellness (FMW) We value the family as the heart of the Alaska Native Community. We work to promote wellness that goes beyond absence of illness and prevention of disease. We encourage physical, mental, social, spiritual and economic wellness in the individual, the family, the community and the world in which we live. • • • • • • • • FMW1. Reduce the rate of Domestic Violence, Child Abuse and Neglect. FMW2. Reduce the rate of and improve the management of cancer. FMW3. Reduce the incidence of suicide. FMW4. Reduce the rate of obesity. FMW5. Reduce the rate of substance abuse. FMW6. Reduce the rate of and improve the management of diabetes. FMW7. Improve oral health. FMW8. Reduce the rate of and improve the management of cardiovascular disease. Copyright © 2011 Southcentral Foundation. All Rights Reserved. Operations Focus - Key Improvements Operational Principles Customer-owner in control Design of our work processes – team based Improvement Model – PDSA and Baldrige Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Operations Focus - Key Improvements Advanced Access – appointments when the customer-owner wants – same day primary care Max Packing Interdepartmental Service Agreements Hospitalists in Pediatrics and Internal Medicine Copyright © 2011 Southcentral Foundation. All Rights Reserved. Operations Focus - Key Improvements Microsystem Optimization -teams • Primary Care: Physician, RN, Certified Medical Assistant, • • CM Support, Behaviorist, Dietician, Pharmacist, office redesign Behavioral Health teams: Physician, Master Level Therapist, Case Manager Human Resources teams: HR Generalist and Assistants – Same day service, etc. Home Health, Nutaqsiivik, Waiver Care Coordination, Home Visiting Physician Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Operations Focus - Key Improvements Traditional Healers – Tribal Doctors Complementary Medicine – Chiropractors, Massage Therapists, Acupuncture Behavioral Health Redesign Facilities and work areas Family Wellness Warriors Initiative Copyright © 2011 Southcentral Foundation. All Rights Reserved. Adverse Childhood Experiences Kaiser Permanente and Centers for Disease Control Over 17,000 participants Types of childhood trauma studied (ACE): Physical abuse Emotional abuse Sexual abuse Household alcohol / drug abuser Incarcerated household member Mother treated violently One or no parents Divorce Emotional or physical neglect Parent who is mentally ill, depressed, or suicidal (ACEStudy.org) Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Adverse Childhood Experiences One type of ACE nearly doubled the risk of perpetrating domestic violence as an adult Four or more ACEs was associated with five times greater risk for domestic violence as an adult • • • • • Physical abuse Emotional abuse Sexual abuse Household alcohol / drug abuser Incarcerated household member • • • • • Mother treated violently One or no parents Divorce Emotional or physical neglect Parent who is mentally ill, depressed, or suicidal Copyright © 2011 Southcentral Foundation. All Rights Reserved. Adverse Childhood Experiences Exposure to one type of ACE increased risk of suicide attempt by two to five times Exposure to seven or eight ACEs Increased risk of suicide attempts by 51 times during adolescence Increased risk of suicide attempts by 30 times in adults • • • • • Physical abuse Emotional abuse Sexual abuse Household alcohol / drug abuser Incarcerated household member • • • • • Mother treated violently One or no parents Divorce Emotional or physical neglect Parent who is mentally ill, depressed, or suicidal Dube SR, Anda RF, Felitti VJ, Chapman DP, et al. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: Findings from the Adverse Childhood Experiences Study. JAMA. 2001;286:3089-3096. Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Video Copyright © 2011 Southcentral Foundation. All Rights Reserved. Check In Discuss how the video impacted you and/or how you connected with the video. Time: 10 minutes Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Customer Focus - Key Improvements Governing board Advisory committees Elders Council Focus Groups Annual Gathering 24- hour hotline Community gatherings Personal interaction with employees Satisfaction surveys Comment cards Copyright © 2011 Southcentral Foundation. All Rights Reserved. Workforce Focus - Key Improvements Interview /Hiring Onboarding (ASTP, etc) Leadership development Development Center Career Ladders Job Progressions Mentoring Employee Wellness Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Would You Like to Live in Alaska? Copyright © 2011 Southcentral Foundation. All Rights Reserved. Are You Sure? Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Development Center Training center Annual reorientation – reaffirm core philosophy (online & manager led components) All staff meeting (annually) • CEO led session • Peer teaching on topics chosen by employees Departments of learning based on workforce competencies • • • • • More than 150 course offerings Partnership with university to award college credits Partner with other learning organizations to develop trainings Courses designed on adult learning theories including experiential learning Instructional designers partner with subject matter experts to develop training Internships (RN, Behavioral health clinicians) Scholarship program Copyright © 2011 Southcentral Foundation. All Rights Reserved. Data and Measurement - Key Improvements Multiple levels Mission, Vision, Key Points Data experts Data and sharing story Data Mall Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Information to Knowledge % Employees with Current Annual Disaster Tng 94 100 98 100 2007 2008 2009 74 % 53 50 0 2005 2006 SCF Industry Best (100%) Copyright © 2011 Southcentral Foundation. All Rights Reserved. 70
    • Then and Now … Copyright © 2011 Southcentral Foundation. All Rights Reserved. Then and Now … Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Health care provider changes No longer a hero but a partner • • • • • Control does not equal compliance Replace blaming with understanding Give customer options, not orders Provide customer with resources Make it simple Copyright © 2011 Southcentral Foundation. All Rights Reserved. Customer-owner changes Be active, not passive Take responsibility for your health Get information about your health Ask questions about advice Ask for options Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Leadership Changes Core Concepts – WELLNESS Role model Willingness to share story Willingness to hear story Admit mistakes Copyright © 2011 Southcentral Foundation. All Rights Reserved. Questions Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Check Out What are you going to change or what can you change when you go back to your organization? Copyright © 2011 Southcentral Foundation. All Rights Reserved. It’s All About Customerownership and Relationships Copyright © 2011 Southcentral Foundation. All Rights Reserved.
    • Thank You! Qaĝaasakung Quyanaq ‘Awa'ahdah Aleut Inupiaq Eyak Mahsi' Igamsiqanaghhalek Háw'aa Gwich’in Athabascan Siberian Yupik Haida Quyana T’oyaxsm Gunalchéesh Yup’ik Tsimshian Tlingit Tsin'aen Quyanaa Chin’an Ahtna Athabascan Alutiiq Dena’ina Athabascan Copyright © 2011 Southcentral Foundation. All Rights Reserved.