Sweeping change, especially in a large and complex health care system, is never as breezy as the phrase implies. Rather, it is the painstaking result of years’ worth of small steps and bite-sized improvement efforts that, when well managed, grow and spread and take hold throughout the organization. But without one fundamental ingredient underpinning it all, says Douglas Eby, MD, MPH, all the work could amount to shoveling sand against the tide.

Eby is vice president of medical services for Southcentral Foundation (SCF) at the Alaska Native Medical Center (ANMC) in Anchorage, Alaska, USA, a large Native owned and managed medical center with more than 425,000 outpatient visits annually, as well as a 150-bed hospital. The primary care system serves the urban sprawl of Anchorage as well as more than 50 remote villages in a 100,000-square mile catchment area that is so large it would be this country’s seventh largest state.

As a change leader who has helped make a reality of the vision of Native owners and leaders, Eby can enthusiastically tick off a dizzying list of process and structure changes that the organization has successfully implemented in continual pursuit of improved care and service. These include innovations such as advanced access scheduling; chronic disease management; sweeping workforce development; full integration of complementary practices; telemedicine; and even telepharmacy dispensing, enabling patients in remote villages to receive prescription medications through a sort of vending machine controlled remotely by pharmacists in Anchorage, complete with web-cam counseling between pharmacists and patients.

SCF/ANMC has plenty of data that demonstrate the potency of these innovations. Patient and employee survey data show that both groups rank ANMC’s performance above national averages in a majority of categories. Clinical data show a 50 percent increase during the past several years in the number of diabetic patients whose HbA1c is at or under 7, as well as immunization rates for children approaching 90 percent, well above the national average.

But amid all the Center’s successes — and there are many — what SCF leaders are most passionate about is the foundation that supports their success: what they term values-driven system design.

Values-Driven Design

“You have to spend a lot of time on the front end of change to figure out both the values that drive the priorities and the structures on which health care is currently based, and the values that drive the priorities of your customers,” says Katherine Gottlieb, MBA, SCF’s chief executive officer. An Alaska Native herself, Gottlieb says, “Health care must be based on the values of the people you serve. Otherwise, there will be a constant clash between providers and customers.”

At SCF/ANMC, the concept of alignment is key. “So many people in health care feel beleaguered because they are stuck between what they view as insatiable patient demands, unreasonable insurer demands, and standards of care that they either want or need to meet. The dissonance among those misaligned priorities is driving a lot of people nuts,” says Eby. “When you align the priorities, that dissonance disappears.”

At SCF/ANMC, aligning provider, patient and payer priorities rests on an unwavering commitment to being truly patient-centered. “We talk about patients as compliant and non-compliant,” says Eby. “Those words should be eradicated from our vocabulary. Rather than trying to get patients to be more compliant, we should figure out if we are being compliant with the wants and needs of our patients.”

This philosophy is especially central at SCF, not only because it serves a predominately Native Alaskan population, but also because it is owned by Alaska Natives. In 1999, in partnership with the Alaska Native Tribal Health Consortium, the Southcentral Foundation, an Alaska Native-owned non-profit healthcare corporation, assumed ownership of ANMC from the federal government. This launched a turning point in the medical center’s approach to delivering care.

“Native cultures have never fully embraced 20th century values,” observes Gottleib. “In the Native community, there is more emphasis on family, more respect for elders, more reliance on common sense and age-old wisdom, and a more team-oriented approach to problem-solving. Native people also tend to be more spiritual, and view the four dimensions of wellness — physical, emotional, mental and spiritual — as inseparable. To be well means being well in all four dimensions.”

This is in contrast to the way American medicine has developed. Says Eby, “In the mid-20th century, the values of the industrial revolution influenced medicine, and the body began to be viewed as a combination of parts, like machines. If you view the body as parts, it drives you toward an approach that relies on specialists to fix specific parts of the machine – particularly through procedures and biomedical manipulation, or medications. In usual modern medicine, physical and mental health are often treated separately, and emotional and spiritual health often not addressed at all. The whole person is not central to the system design.”

With the transition to Native ownership and management, SCF leaders set about defining the changes they wanted to make in the system. “Katherine and the Board led the way, and continue to lead the way, to clearly defining the system’s values, priorities, and goals – and overseeing its evolution,” says Eby. “Their strong vision and leadership made it much easier at an operational level to create passion and alignment. They have empowered us to adapt best practices that are in alignment with our goals and systematically put them in place over time.”

Conflicting Values

Gottlieb, Eby and others from SCF are in demand as speakers these days, and they offer audiences a step-by-step outline of how to think about aligning a health care system with patient values. The SCF presentation is long and detailed, and reflects the remarkable focus, persistence and commitment that the organization has demonstrated on its own journey of change.

SCF leaders contend that the strong influence of western values on American health care has resulted in a system that respects:

• Separation of body and mind, disregard of spirit and emotion
• Compartmentalization of body into organs
• Organ specific specialists
• Illness understood as infection by outside agent, biochemical imbalance, or breakdown of ‘machine’ needing surgical intervention
• Illness as an individual experience
• One-on-one visits
• Treatment through medicine and surgery
• Knowledge from books
• Publications as the source of new knowledge
• Centralized institutionalization of ‘ill’
• Patients who are ‘compliant’
• Patients who are passive

SCF/ANMC leadership asks itself continually what a system built on Native values should look like. They envision — and continually work to create — a system that:

• Emphasizes the extended family and the group, drawing on their strengths
• Develops a system of experienced mentors
• Places counselors, case managers, care coordinators in central roles
• Treats the family rather than the individual
• Creates healing physical environments
• Emphasizes sharing, mutual support, partnering
• Integrates spiritual, mental, physical, emotional health – really!
• Involves more touch
• Respects home prepared remedies
• Avoids institutionalizing people to minimal levels

But what does this mean in practical terms?

For SCF/ANMC leaders, it means embracing a single overarching paradigm that drives every part of the system. “The cornerstone of our entire system is the support of long-term, trusting, continual relationships,” says Eby. “The extended family or household is the unit around which our system is designed, and our focus is to support their relationships with one another as well as with us.”

To support this paradigm, the organization developed 13 operational principles — the laws of the system — that guide the development and operation of all programs and systems. The principles are carefully written so that the first letters of each one, taken in order, spell out RELATIONSHIPS. They are:

Relationships between the customer/owner, the family, and provider must be fostered and supported

Emphasis on wellness of the whole person, family and community including: physical, mental, emotional and spiritual wellness

Locations that are convenient for the customer/owner and create minimal stops for the customer/owner to get all of their needs addressed

Access is optimized and waiting times are limited

Together with the costumer/owner as an active partner

Integration of services throughout all of SCF. No more islands

One seamless system

No duplication of services or roles and responsibilities

Simple and easy to use systems and services

Hub of the system is the family

Interests of the customer/owner are placed first and the system is created around what works best for the customer/owner

Population-based systems and services

Services and systems are culturally appropriate and build on the strengths of Alaska Native cultures

The relationship at the center of this paradigm is that of the patient and his or her primary care team. With the patient as the hub, the team includes the patient’s family, the primary care physician, a nurse case manager, certified medical assistants, case management support, a social worker, and a behavioral health specialist. Additional ”virtual” team members include health educators, midwives, nutritionists, and pharmacists. Many specialists (including chiropractors, massage, acupuncture and ”usual” medical specialists) are ”layered” in.

Integrated Care Without Duplication

Advanced access scheduling, put in place with IHI’s help nearly five years ago, makes it easy for patients to see their team members when they want to. “Any barrier to access decreases the relationship,” says Eby. When same-day visits with a chosen primary care physician became a routine option, use of the Urgent Care Center and ER for primary care fell by 50 percent. Indeed, more than 80 percent of patients see their designated primary care physician when connecting with the system, compared with just 35 percent eight years ago.

Because the primary care team is the central point of contact for patients, use of specialty care is down by 65 percent. Integrated care is a key principle at ANMC, and that includes integration of complementary medicine, such as chiropractic, massage therapy, healing touch, and tribal doctors who are Native Traditional Healers. “These are not alternative options, they are fully integrated into our system,” says Eby.

Fully integrated care at SCF/ANMC means that every part of the system is intentionally planned to avoid duplication and maximize unique capabilities. “When we look at a service or an individual, we ask, ‘What are you uniquely qualified to do in our system?’”says Eby.

For instance, in freestanding chiropractic clinics, the range of problems treated can be quite wide. At SCF/ANMC, chiropractors are limited to the treatment of acute pain in the neck, shoulder, and upper and lower back. Similar role definitions are in place for massage and acupuncture practitioners, and for all staff.

SCF/ANMC’s use of hospitalists is another example, keeping primary care physicians more available in the office. Ob/Gyns, too, are almost like subspecialists. “Our family doctors and midwives are fully competent to care for routine Ob/Gyn needs,” says Eby. “The Ob/Gyns serve as high-end consultants on the more complex cases. At first they were upset that we were limiting their practice, but now they are among the happiest in our system because they focus on the more challenging cases.”

Having created disease-specific primary care teams in the mid-90s when the concept was gaining popularity, SCF/ANMC has since dismantled them. “Everything we do, we stack up against our list of operational principles,” says Eby. “We looked at our immunization team, our HIV team, and asked, ‘Does this treat the whole patient? Is it family-oriented? Does it avoid duplication?’ The answer in each case was no. It is our strong contention that it is much better to deal with the whole person in their medical home. We do have diabetes specialists, but their job is to make sure that all the primary care providers are optimizing treatment for their diabetic patients.” The same is true for all disease-specific specialists.

Supporting the Workforce Through Continual Change

Creating and sustaining this continual commitment to change can take its toll on staff. So as members of IHI’s IMPACT network, SCF/ANMC joined a Breakthrough Series Collaborative on workforce development. “Like everything we do, we set about putting in place whole system optimization of all known best practices,” says Eby. “As one example, wee have created job progressions for nearly every position we have – including nurses and doctors – structural ways to drive increased competencies and maturity.”

Under the leadership of Michelle Tierney, Director of Organizational Development, and Sandy Bohling, Human Resources Director, a myriad of system elements have been intentionally redesigned and built into better alignment and integration with everything else at SCF/ANMC. “We have far exceeded our goal of decreasing turnover by 50 percent in nursing and administrative support and front desk staff,” says Tierney.

Helping new staff understand the organization’s commitment to its operating principles is key to their ability to fit into the culture, says Tierney, “so we redesigned our orientation process. At the corporate level new employees get a three- to five-day orientation. At the department level they get another orientation that includes lunch out with a mentor who will continue to work with them over time. We use behavioral-based interviewing, which helps us determine the ‘fit’ better and we have implemented same day hire, meaning the time from application to hire is now measured in hours rather than weeks for many of our positions.” And while most organizations throw parties for departing employees, at ANMC the opposite is the case. “We are working on celebrations when people arrive,” says Tierney. “We want them to know they are part of something big.”

Indeed, what could be bigger than, as Gottlieb puts it, changing the very DNA of the system? “It is the only way to create and sustain lasting change,” she says. “Everything you do, your incentives, rewards, how you train and orient staff, it all becomes aligned because you are running a system where the rules are clear, and the intention is clear, and they are all based on our principles. And if people ask why something is done here a certain way, we say it’s because we found out the values of the community we serve, and we committed ourselves to building a system based on those values, a system that’s truly patient and family-centered.”