Nuka! South Central Foundation of Care

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.
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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


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

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


Katherine’s Story


Check In
Discuss how you connected with Katherine’s
story and/or how did Katherine’s story impact
you.
Time: 10 minutes


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)


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


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


SCF Board of Directors


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


Key Points
Shared Responsibility
Commitment to Quality
Family Wellness


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


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.


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


Customer Ownership

1982 - Fewer than 100 employees
and budget of $3million

2013- 64,000 customer-owners; 1,600
employees; budget $227million


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


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


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


Why Listen to Our Story


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


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



Doug’s Story:


Check In
Discuss how you connected with Doug’s story
and/or how did Doug’s story impact you.
Time: 10 minutes


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


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


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


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)


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’


Hitting Target: Rock vs. Bird


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


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


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


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?


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



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


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


Check in
Discuss what you would change in your
healthcare system if you owned the healthcare
system.
Time: 10 minutes


Customer-owner
Southcentral Foundation uses the term customerowner instead of:
• Patient
• Client
• Customer


Questions


Leadership - Key Improvements
Our vision
Shared Responsibility
Core Concepts
Board of Directors
Role model
National, regional and local
partners
Functional Committee
Structure


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


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


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


Strategic Planning
- Key Improvements
Mission, Vision and Key Points
Relationships across the organization
Customer-owner input



Linkages
EVERYTHING TIES TOGETHER!


SCF Strategic Planning Cycle


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.


Operations Focus
- Key Improvements
Customer-owner in
control
Design of our work
processes – team based
Improvement Model –
PDSA and Baldrige


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


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


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


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)


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

•
•
•
•
•

One or no parents
Divorce


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

•
•
•
•
•

One or no parents
Divorce

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.


Video


Check In
Discuss how the video impacted you and/or how
you connected with the video.
Time: 10 minutes


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


Workforce Focus
- Key Improvements
Interview /Hiring
Onboarding (ASTP, etc)
Leadership development
Development Center
Career Ladders
Job Progressions
Mentoring
Employee Wellness


Would You Like to Live in Alaska?


Are You Sure?


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


Data and Measurement
- Key Improvements
Multiple levels
Mission, Vision, Key Points
Data experts
Data and sharing story
Data Mall


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%)


70

Then and Now …


Then and Now …


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


Customer-owner changes
Be active, not passive
Take responsibility for your health
Get information about your health
Ask questions about advice
Ask for options


Leadership Changes
Core Concepts – WELLNESS
Role model
Willingness to share story
Willingness to hear story
Admit mistakes


Questions


Check Out
What are you going to change or what can you
change when you go back to your
organization?


It’s All About Customerownership and Relationships


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


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