Healthcare 3.0 The Nuka System of Care Doug Eby, VP of Medical Services Steve Tierney, Medical...

Healthcare 3.0 The Nuka System of Care

Doug Eby, VP of Medical Services

Steve Tierney, Medical Director/CMIO

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.

3 Sections of Content1. Basic history and approach of SCF and Stages of

SCF’s PCMH evolution2. Tools to manage Team Dynamics and Population

Modeling3. Understanding Interactive use of Team Tools

Goal is to get clarity about where your system is and what steps you might take to create change

Learning Objectives

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


Key PointsShared ResponsibilityCommitment to QualityFamily Wellness


Relationships between customer-owner, family and provider must be fostered and supportedEmphasis on wellness of the whole person, family and community (physical, mental, emotional and spiritual wellness)L ocations convenient for customer-owners with minimal stops to get all their needs addressedAccess optimized and waiting times limitedTogether with the customer-owner as an active partnerIntentional whole-system design to maximize coordination and minimize duplicationOutcome and process measures continuously evaluated and improvedNot complicated but simple and easy to useS ervices financially sustainable and viable Hub of the system is the familyInterests of customer-owners drive the system to determine what we do and how we do itPopulation-based systems and servicesS ervices and systems build on the strengths of Alaska Native cultures

Operational Principles


If you could own completely your own healthcare system, what would you do –as a customer-owner?

We had that choice – and chose to fundamentally rethink and redesign every single thing in the entire system.

We kept the best that modern medicine has to offer and we kept the medical professionals, but we redefined the fundamental understandings, redefined the ‘core concepts’, and changed dramatically the whole system platform.

Customer Control at both the macro and micro level – shared partnership, commitment to quality, family wellness.

Customer Control


Over 25 years of history Innovative, relationship based, customer driven systems

1,500 staff – 140,000 statewide clients55,000 local clients including 10,000 in over 50 remote villages

Expanding local population (7%/yr)

Southcentral Foundation


Medical Services – Primary Care, Women’s Health, Pediatrics, Optometry

DentalBehavioral Health – clinics, residential treatments, after-care, youth, elders

Family Wellness Warriors – abuse and neglect treatment and prevention

Tribal Doctors and Traditional ServicesChiropractor, massage, acupuncture

Southcentral Foundation


Evidenced-based generational change reducing family violence

50% drop in Urgent Care and ER utilization 53% drop in Hospital Admissions 65% drop in specialist utilization 20% drop in primary care utilization 75-90%ile on most HEDIS outcomes and quality Childhood immunization rate of 93% Diabetes with 50% of HbA1c below 7% Employee Turnover rate less than 12% annualized Customer and staff overall satisfaction over 90% In an urban Alaska Native community with huge challenges

Why Listen to our Story


Defining the purpose – relationship over timeUnderstanding complexity science - principlesMoving from product to service as the fundamental base of entire system

Optimized primary care with redefined entire system on that ‘new’ backbone/platform

Customer driven design – reallocation of power and control at every level

Optimizing messy human relationships

The SCF Nuka System


Attempting to isolate a single intervention as the approach to change within a complex dynamic system assumes all other processes, events and participants remain static over time. Is that a reasonable expectation?

Risk of Reductionism


Outcome not income Person not disease Population not process Service not practice

Approaching the Philosophic Thought Process of Redesign


1.Never disturb the workforce without clear cause and plan. No plan is better than a bad plan2.Always design for what happens 85% of the time for 85% of events3.Always create methods to identify exceptions to “85/85” so appropriate adjustments can occur4.Always design second and third level plans for exceptions to the “85/85 rule” rather than primarily over over-designing for all events5.Always analyze before repair, look for patterns or clusters, remember rule #16.Always when improving, extremes of performance are more instructive than averages to quantify progress. Segmentation is critical, trends are more important than current performance7.Never train entire groups when you can target only those at variance8.Always intervene from the “back not the front” where possible. Identify those doing well and recall rule #1. Always fix what is broken. Always spread what works 9.Always, the first step in change is to design the ability to measure. Never intervene without it10.Never build a pathway without attaching a measure that can be applied to the entire denominator without reviewing charts or requiring individual case review. Pathways are not measures. They “suggest” visit based, provider driven decisions.

10 Tips for Redesign


Segmented measurement by individual Integration of traditionally separate work types

Team dynamic optimization Including Customer as an equal partnerData Modeling and pattern recognition “Smart Systems” that suggest both diagnoses and plans

Stages of PCMH Evolution(not to be confused with

levels)


Changing from organizational level data to segmentation down to the work team or individual level.

Operational and business model unchangedMeasurement is segmented but not responsibility for measurement which still stays with leadership

Resources are still allocated and analyzed from a system wide level

Leadership still focused on system wide measurement

Stage 1 PCMH


Integrating teams with roles traditionally separated in older work systems

More customer focused work flow prospective Usually accompanied by changes in floor plan and office space

Often results in more wide variation in performance between teams

Professional staff often not prepared or trained to work in interdisciplinary environment

Stage 2 PCMH


Shift to team dynamics and team skill buildingMove away from traditional workflows with visit basis or clinical focus toward team awareness and optimization

Reorganize data to discover variance in team performance and spend efforts to understand reasons around variance

Focus more on outcome as opposed to process

Stage 3 PCMH


Recognizing the value of the customerUnderstanding patterns of use and non use are instructive and are comments on the ease, effectiveness and satisfaction with your larger system

Adding infrastructure to learn directly from the customer base, more than just advisory or focus groups

Stage 4 PCMH


Data modeling for pattern recognition as a tool/strategy

Segmenting costs and work volume by methods other than disease

Adding new methods of intervention to address variance within new segments

Reorganizing workforce to more effectively manage newly exposed performance gaps

Stage 5 PCMH


Using previously identified patterns to trigger smart systems that suggest best approach or plan

Incorporating these smart systems into infrastructure available to both consumers and staff

Stage 6 PCMH


Team Tools and Approaches


What are we really trying to accomplish – optimal individual health at a population level, with a good experience of care, and at an affordable cost – the Triple Aim

Has the 75 years of the Medical Model gotten us there? Yes – Trauma, Infectious disease, broken parts – fixing

and eradicating No – Living with long tern health challenged and

conditions – now 60-70% of healthcare cost – and growing

Backing Up – Purpose?


Control: Who really makes the decisions

Acuity

“Control”

The “System”

Customer-owner/Family

0 Low High

100

1. Control – who makes the final decision influencing outcome?2. Influences – family, friends, co-workers, religion, values, money3. Real opportunity to influence health costs/outcomes – influence on

the choices made – behavioral change4. Current model – tests, diagnosis, treatment (meds or procedures)


Low High complexity - variables

Complexity

Low

High

Cer

tain

ty o

r A

gre

emen

t

Protocols & Stds

Chaos

Some simple rules for improvement

Experimenting

Get together and have dialogues

An allowing/positive

environment

Multidimensionalimprovements with

target focus Creativity

complexity diagram


Why do people come to us – concerns from new signs and symptoms, changes to be managed, interpreting confusing messages, and supportive coaching advice, medications

So, how can we understand what makes up our work - • Diagnosis• Prescribing• Procedures• Teaching, Coaching, Advising• Encouraging• Calming, soothing, reassuring

OK – What To Do


Of that list – what needs to be handled in person, video, email, text, phone?

How do people handle other parts if their lives?Only two areas left not revolutionized by the Digital-Software Revolution – Healthcare and Education.

How would Facebook or Google design how to address the reasons people seek out healthcare professionals?

So, Then, What To Do…


Provider

Chronic Disease

Monitoring

Customer

Preventive Med

Intervention

Mental Health

Provider

Referral to Specialist

after Assessment

Medication Refill

New Acute Complaint

Customer Customer

CustomerCustomer

CustomerCustomer

Customer

Certified Medical

Assistant

Case Manager

Test Results

Customer

Health Care

Support Team Dietitian

Clinical Pharmacist


Traditional Methods of Managing Work Flow

Parallel Work Flow Redesign

Health CareSupport

Team

Chronic Disease Monitoring

Preventive Med

Intervention

Certified Medical Assistant

Clinical Pharmacist

Medication Refill

Undiagnosed or Changing New

Consumer Concern

ProviderCase

Manager

Management of Study /Test Results Info

In Clinic Point of Care

Testing

Chronic Disease

Compliance Barriers

Acute Mental Health

Concern

Customer

Customer

Customer

CustomerCustomer

CustomerCustomer

Customer

Customer

Dietitian

Behavioral Health

Consultant

Customer

Customer Customer


What are the logical consequences of thinking differently? • Team Members• Methods of Communications• Physical Space • Payment Methodology• Core Skill Set• Training and Education

Consequences…


In place at SCF…• De-Officing everyone – intentionally designed team spaces

• Elimination of Nurses Stations• De-medicalizing encounter spaces• Integrated Care Teams – Whole person, family• Virtual visits

Consequences


Logical Extensions of this…• Rethinking Specialist roles• Rethinking Hospitals• ‘Pull Discharges’• Weaving Communication and services into THEIR lives

Consequences


PCP - Primary Care Provider-DOC, NP/PA

Nurse Case Manager Case Management

Support Certified Medical

Assistants Behaviorists Dieticians

The Integrated Care Team


Pharmacist (partially implemented)

Nurse Midwife (partially implemented)

Coverage NP/PA/CM’s Co-located Psych

(pending) Coders, Data entry, etc. Front Desk

Up front training for CMAs and Admin SupportNative professional development Hiring Practices – Same day, behavioralOrientation and Mentoring intentionallyEmployee Development CenterPAP’s, Job progressions, career laddersSummer and Winter InternsKEY – All staff ‘expert” in improvement

Workforce Development


Extensive training and formal mentor systems for front desk, CMA’s. others in place for sometime already

Now expanding to physicians, nurses, other clinical staff – Partially implemented only at present

Commitment to extensive training by outside mentoring systems and experts – deeply incorporated into all of SCF over time

One mentor for every three clinical staff

Mentors – Clinical Mentors


The Nuka Method for Creating Change

Practical Use of Tools for Managing and Coaching

Teams


Identify key strategies in using effective communication tools that can improve adult learning in meetings and open forums

Apply effective listening skills and recognize the importance of maintaining correct interpretations of an individual’s communication intentions

Objectives


Intro to Core Concepts – The Power of Sharing Story• Connection to your story• Respond to people from your heart• Walk beside others with empathy

Core Concepts


Guiding principles each employee should use in every interaction in order to create healthy relationships

Every person has a story, that story influences both prospective and reactions

Understanding that story offers the opportunity to identify and understand both barriers and opportunities for change

Definition of Core Concepts


Core Concepts: Work together in relationship to learn and grow

Encourage understanding

L isten with an open mind

L augh and enjoy humor throughout the day

Notice the dignity and value of ourselves and others

Engage others with compassion

Share our stories and our hearts

Strive to honor and respect ourselves and others


Better at communicating and working together with our customer-owners and each other in order to achieve our mission and vision

Increase in customer-owner satisfaction Increase in the climate of trust for employeesProactive in making a change on major issues facing our community: Domestic Violence, Sexual Abuse/Assault and Neglect

So Why FWWI and Core Concepts Training?

Core Concepts Training is about a set of tools to enable employees, wherever they are on their own journey, to increase their capacity to relate to those with whom they work

Better relationships = healthy customer-owners AND healthy employees

Bottom Line


Establish a safe environmentBuild Trust Lay the foundation for full participation and interaction

Get acquainted

Learning Circle Guidelines


Go off dutyAppropriate behaviorsExpectations of confidentialityAttendance Stories and responding to Learning CirclesSelf-Care

• Care Team availability

Core Concepts Boundaries


A record or narrative description of past events

In Alaska Native culture sharing story is done to show values, pass on skills, and in some instances, show why and how something is or came to be

What is a 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

Levels of a Story



Sharing your Story The depth of story you share is always up

to you.

You have the permission to go where ever you are comfortable going.


Healthy Responses to a StoryMatch your response to the level of story that is shared

Give Authentic ResponsesSpeak from your heartGive responses that should make it safe for the person to tell more of their story

Keep responses without judgment

Responding to Story



The shape you are in exercise



Mental ModelsMental Models are established by past events, experiences, media and other messages we receive, and serve going forward as filters through which we observe, interpret and respond to the world

They shape what we see and hear, what we feel and what we do

Mental Models give birth to stereotypes



Mental Model - Marriage

Some think• Ball and Chain• Shackles• Prison• No more dating

Some think• Security• Celebration• Happiness• Life Partner



Left-Hand Column

A method developed by Chris Argyns and David Schoon to reflect on the quality of a

conversation by analyzing it from two perspectives.



Left Hand Column Activity

Left –Hand Column• What I thought and

felt but didn’t say

Right-Hand Column• What was said

(actual dialogue)



Dialogos Int’l LLC & SOL, Cambridge, MA

Quality Interactions 4 Player Model



Kantor’s Four Player System

FollowWithout Followersthere is no Completion

BystandWithout

Bystandersthere is no

Perspective

MoveWithout Movers

there is no Direction

OpposeWithout Opposers

there is no Correction

© 1995 David Kantor




Bystander

Opposer

Follower

Mover

PerspectivePatience

PreservationModeration

Self-Reflection

CorrectionCourage

ProtectionIntegritySurvival

CompletionCompassion

LoyaltyService

Continuity

DirectionDiscipline

CommitmentPerfection

Clarity

Action Intends:

DisengagedJudgmentalDesertingWithdrawn

Silent

CriticalCompetitive

BlamingAttackingContrary

PlacatingIndecisive

PliantWishy-Washy

Over-accommodating

OmnipotentImpatientIndecisiveScatteredDictatorial

But sometimescomes across as:

Bystander

Opposer

Follower

Mover

Action Positions

© 1995 David Kantor




Exercise - 4 Player Model

1. What role are you most comfortable in? OR in which role do you find yourself most often? (home and work)

2. What role are you least comfortable in ? OR in which role do you find yourself the least often or have to really care before you go into that role? (home and work)

3. What role do you want to work on improving? What can your learning circle partners help you work on in the next few days?




Features of Stuck Groups & Teams Individuals get locked into a single action

Opposers are punished by the group, or they dominate There are no strong Movers, or no one Follows a move. The Bystander is disabled. Individuals attach double messages to their moves Ritualistic and unproductive patterns of behavior prevail The team is unable to reach closure and produce results Lack of capability or flexibility to engage in all four

action behaviors Individuals gravitate to favorite behaviors (and are type

case in roles by others)




Features of Balanced Groups & Teams Capability to engage in all four actions (move,

follow, oppose, and bystand) in observable balanced sequences.

Individuals have the flexibility to engage in more than one of the behaviors.

The group and individuals do not get caught in repetitive or ritualized patterns of behavior.

The group has an active, enabled bystander function which helps it inquire and stay unstuck.

People in the group are able to make clear, rather than mixed or ambiguous moves.

The group is able to reach closure and produce results.




Providing Space – when One or More Dynamic is Missing

4 Player-Role

Intent If I want to take on role, then I might say

If I want to get someone to take the role, then I might say

Move Provide direction “I think that we should XX, John, would you…”

“John, what do you think we should do?”

Follow Commit to trying another’s direction

“That is a great idea! How can I help?”

“How can we support Peter’s suggestion?”

Oppose Raise differences for purposes of testing

“An alternative approach might be to…”

“Does anyone see anything in this that might not work?”

Bystand Test your view of what is happening

“I’ve noticed that we’ve been circling the same topic for some time. Perhaps we want to…”

“What are we overlooking?”



CDR Profile



5 Dynamics Dimensions

Explore Excite Examine Execute Evaluate



5 Dynamics Person to Person



5 Dynamics Team



New Ways of Thinking About Customer and Staff

InteractionsDiabetes Depression CVD

Struggling Alone, 20-45 y/o single parent not employed

Communication and interaction strategy based on risk, cost and level of control

Thriving Alone, 20-35y/o single no dependent, employed

Urban Cliff Climbers, 20’s single and working, multifam house

Retired in Suburbs

55+ often couples in large SF homes


Thank You!

Qaĝaasakung

Aleut

QuyanaqInupiaq

Háw'aa Haida

‘Awa'ahdah

EyakMahsi'Gwich’in

Athabascan

Igamsiqanaghhalek

Siberian Yupik

Tsin'aenAhtna Athabascan

T’oyaxsmTsimshian

Gunalchéesh Tlingit

QuyanaYup’ik

Chin’anDena’ina Athabascan

QuyanaaAlutiiq



Questions?Please contact:

Erica SrisanehaSouthcentral [email protected] log onto our website at www.scf.cc/nuka


Healthcare 3.0 The Nuka System of Care Doug Eby, VP of Medical Services Steve Tierney, Medical...

Documents

Transcript of Healthcare 3.0 The Nuka System of Care Doug Eby, VP of Medical Services Steve Tierney, Medical...