After helping Southcentral Foundation perfect the art and science of advanced access scheduling in the 45,000-patient clinic where he works, Douglas Eby, MD, MPH, somewhat unexpectedly, says this: "We want to tell the world: It’s not about access. Access is only a tool that helps create relationships because it breaks down barriers. Relationships are really what it’s all about." It is only through solid relationships, says Eby, that you can begin to get at insidious underlying health issues such as depression, domestic violence, and obesity.

Eby is vice president of medical services for Southcentral Foundation (SCF) at the Alaska Native Medical Center (ANMC) in Anchorage, Alaska, USA, a Native owned and managed 150-bed hospital and large medical center with more than 375,000 outpatient visits annually. The clinic 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 America’s seventh largest state.

The story of ANMC is the story of remarkable vision, persistence, progress and change. It is the story of how this once federally-owned clinic — "a big, impersonal, ‘crank-‘em-through’ type place," says Eby, where most primary care was delivered in urgent care or emergency room settings — transformed itself into a customer-owned and directed system that provides same-day access to holistic, integrated, family-centered primary care.

Indeed, the transition can be seen in the many run charts produced regularly to help ANMC leaders track their progress.  

When Eby tells the ANMC story — and he tells it a lot these days — he doesn’t need to dramatize the extent of the changes he has seen in his twelve years there. The facts speak for themselves.

In 1994, he says, there was no real primary care system at the clinics. Most area residents got their primary care at the emergency room, when they got it at all. "The clinics were in the hallways; there were no receptionists or waiting rooms. The services were centered on the staff’s needs, not the patients’. There was no budget tracking or accountability by department, and every department was an island."

But in 1999, a significant change took place. "The Medical Center came under Native ownership," says Eby. The Southcentral Foundation, an Alaska Native-owned non-profit healthcare corporation, in partnership with the Alaska Native Tribal Health Consortium, assumed ownership and management of ANMC. The new owners brought with them a new value system, and a determination to transform the clinic into a customer-centered system.

They had their work cut out for them. The average delay to schedule a routine appointment was four weeks to several months. The "no-show" rate was about 25 percent. Phone wait times were in excess of two minutes, and waiting time to see the provider in the primary care clinics averaged 30 minutes. Moreover, even after starting a limited primary care system in 1996, only 35 percent of the total local population had a designated primary care provider. Of those, 43 percent did not even know who that provider was.

Where to begin? "You have to make decisions based on what works best for your customers, period," says Eby. "Most health care organizations don’t really do that."

So they began an extensive process of talking with their customers. Having worked with the Institute for Healthcare Improvement (IHI) since the early 1990s, primarily through participation in the Quality Management Network (QMN), they applied many of the improvement tools and ideas they had learned, and began to design a system around their patients’ desires. The plan itself took four months to create, and included principles, a detailed description of the care model, expected outcomes, and a timeline. It took two years to implement.

Today, the picture is quite different.

For the past three years, patients have been guaranteed same-day access to their own primary care provider if they call by 4:00 PM. Use of the Urgent Care Center for primary care is down by 50 percent; the use of specialists is down by 30 percent. The patient-provider match is between 75 percent and 80 percent. Wait times have decreased significantly across the system.

Clinically, the entire system has been re-organized to provide integrated primary care. "We abolished disease-specific teams," says Eby, "and put all those people in the primary care system. Those nurses are now comprehensive primary care case managers working with the doctors. We can’t afford to have a different team for every disease. And what about people with multiple conditions? Which team do they get? So we put all our eggs in the holistic basket. And our evidence shows we have the same or better rates of diabetes control, mammograms, pap tests, colorectal screening, immunizations."

Social services, nutrition and health education are all integrated into the primary care system. In fact, a new and inviting patient education and resource center has been located in the lobby of the Primary Care Center, says Eby, as well as community gathering spaces, a Native healing center, and an Internet café.

A comprehensive screening program for depression has been put into place, as well as a chronic pain management program. Clinical pathways have been created and are measured and modified by a cross-disciplinary team. Interdepartmental agreements are written and signed annually, laying out exactly how everyone will work together, support each other, and focus on the patient.

The importance of Native clinic leadership for the population the clinic serves cannot be overstated, says Eby, who, as a non-Alaska Native is in the distinct minority among ANMC staff. "The whole system harnesses the power of Native traditions. Native culture and values are at its core," he says, citing the Native emphasis on wholeness, relationship, family, and community. "Our success helps in the journey toward wellness because it generates pride," he says. Southcentral Foundation also has a comprehensive program of workforce development and training for career advancement for Alaska Natives, and they’ve joined IHI’s IMPACT Network to bring focus to their work in this area.

The steps that SCF took to get from where they were to where they are today are too numerous to list here. Their advice and guidance, born from experience, is widely sought, particularly among other public health provider groups.

Here are a few selected "reinvention must-do’s" on SCF’s list:

• Define the mission (built around the customer) and make it real.
• Drive customer-based change from the top down, use a systems approach, and make sure the "drumbeat" comes from all levels.
• Involve staff in planning and development of the new system.
• Define a single operational paradigm (in ANMC’s case, it was to centralize care around patients not diseases).
• Align all support and specialty systems.
• Align incentives ("extremely important," says Eby).
• Celebrate successes (while ANMC staff put in extra hours to work off the appointment backlog in preparation for advanced access scheduling, they were provided with carts of food and beverages and professional chair massages).

The central SCF structures include use of care teams and intensive case management; chronic illness management; use of clinical pathways; and advanced access scheduling. But, cautions Eby, "Advanced access is the first step of a long journey. It’s not the first 20 steps, it’s the first step."

Eby and the SCF system seem energized by the progress the clinic has made during these years of intensive work, and he heaps much of the credit on his colleagues and the vision of Native leadership. He does not pretend it has been easy. "This is a huge amount of hard work to do and to maintain," he says. "You have to be committed to doing something beyond the ordinary. But that’s really the only way to provide health care. Anything less, and you’re just treading water."