Healthcare Culture
Health care is often ruled by culture. When asked why something in a hospital does not change or improved the answer is, “it is hard because this is the culture of this institution.” That excuse has been used for everything from why hospital cafeteria food is unhealthy to why it takes so long to turn operating rooms over to get more patients through the system. Inefficiency is blamed on “the culture.” To change means that bureaucracy has to change, and that starts with governance. The “way we have always done it,” has to give way to something new. But there has to be a willingness and a vision – and more important, you have to know what your customers think.
Of all the most engrained cultures, the most bureaucratic institutions are agencies of the government. Alaska Natives were under the care of the Indian Healthcare service, a system that was originally in the Department of War.
But what emerged originally was a hospital, built, in 1952-3, which was state of the art for its time. A big, beautiful new building that dominated the skyline of Anchorage, Alaska. The hospital was built for the plague of tuberculosis. Prior to that time healthcare for Alaska Natives was limited to teachers, missionaries, army and naval physicians, and outreach programs. It was a disaster, and Alaska was a death zone of tuberculosis, influenza, measles, and other infectious diseases.
Primary Care the Early Days under IHS
When the Alaska Native Hospital opened in 1953 it didn’t have an emergency room (the emergency room came in 1973). Outpatient services were not a part of the plan. The hospital was built because of the urgent need for Alaska Natives suffering from tuberculosis, the leading cause of death of Alaska Natives. Tuberculosis was the reason the US Congress approved emergency funds for the Anchorage Native Hospital, as a sanitarium for isolation and treatment of tuberculosis. There was little evidence that sanatoriums worked at all. But it was the accepted therapy at the time. The outpatient needs of Alaska Natives, and overall health of Alaska Natives were not a consideration. When the hospital opened in 1953 the population of Anchorage was just under 50,000 and the majority of Alaska Natives lived outside the Anchorage area.
Shortly after the hospital opened it became clear there was a need for some clinics. The original outpatient clinics were primarily designed to be used for the inpatients. Inpatients of the hospital might be there for months, or even a couple of years as their TB was treated and monitored. The original clinics provided services for ophthalmology and ENT for those people who were inpatient.
Two things happened that emphasized the need for primary care and outpatient services.
The first was the population of Anchorage increased, and more Alaska Natives moved from the village into the city. The outpatient needs grew. The clinic that originally started with two exam rooms and offices and an ENT exam room.
The second was that tuberculosis was being successfully treated with antibiotics, and could be treated even more effectively in an outpatient setting.
The increased need for outpatient care was not met with increased space. It did mean increased waiting, an overworked staff, and an attempt to just get through the day.
For the early years (1953-1960) there was one doctor, one nurse, and a part time clerk to cover the outpatient clinic. More personal were added as time went on. For years there was a record that one doctor saw over 150 patients in a day. Physicians looked at this number with pride for many years, thinking they had done great work in getting through so many people with so many needs. But seeing that many patients is not conducive to building relationships. Seeing a lot of patients, without a relationship is a perfect recipe for physician burnout.
Outpatient clinic visits rose from 5000 a year when the hospital opened in 1953 to over 13,000 by the early 1960’s. Even though there were speciality outpatient clinics added, often the internist would cover those patients also. Overworked staff, too many patients, not enough time. This was how the hospital started with their outpatient work.
Even twenty years into the hospital’s outpatient efforts there was little in the way of innovation in the care of patients:
” When entering the small ‘waiting room,’ we carried with us our medical records that had taken no less than half an hour to secure from the administrative file room. We spoke through a round metal plate to a person seated behind a large foggy glass structure that went to the ceiling and circled the entrance to the providers area behind her. It was to secure a place in the long line of people waiting to see a doctor. The room had plastic, uncomfortable, dirty looking chairs for people to sit in. It was always messy with dirty tissues, magazines, used cups and other leftover items from people waiting before us. It was always crowded, smelling like rubbing alcohol and sweaty people. The paint on the walls were crumbly and the floors were cracked. We would settled down after checking in to wait – usually no less than seven hours. When our case number was called, we were told what exam room to enter.
In the exam room we were usually greeted by a scowling, tired nurse and provider. Many times we were treated as “drug seeking patients”. And/or given quick exams, quick fixes and out the door with pills. Staff were rude and patients felt like cattle instead of people being run through a hospital.”– Katherine Gottlieb interview
Much like any government bureaucracy, change was something that required an act of Congress to add more physicians to the staff and later the way healthcare would be done. Healthcare was done by a dedicated group of United States Commissioned Corps officers who thought they were doing the best they could with the resources they had.
When you read accounts of those early days, such as Robert Fortuine’s book about the hospital (Fortuine, R, Alaska Native Medical Center: A History 1953-1983) you get a sense of pride in their achievements. What they never did was ask the population they served what they thought. Seeing all those patients in a day represented attaining a goal. Lots of performance, but nothing about outcome. The problem was, the outcomes were horrific. Infant mortality was 50 times worse than in the lower 48 (86.6 per 1000 live births), lifespan was about 35 years, average age of death was less than 31 years old, and the major cause of death was tuberculosis.
Today this is one of the primary care buildings for Alaska Natives owned by SouthCentral Foundation. Our mission is Working together with the Native Community to achieve wellness through health and related services.
Primary care physicians who treat many patients know the feeling well. Too many patients coming in the door, low reimbursement, meaning a primary care physician needs to see forty or more patients a day just to pay the overhead.
When reading what the physicians who took care of the Alaska Natives thought when under the IHS, they felt great after a long day of clinic. In their minds they had seen many patients, which they equated with taking care of their problems, and to improving the overall health of Alaska Natives. They didn’t see the side of it from their patient. They also didn’t bother to compare the health metrics of the patients they were seeing to the US.
If they had asked, they might be shocked by what they heard. In some ways it was “accepted” as the way things were.
Healthcare is still trapped into this mode of thinking. The more patients can be put through, the more encounters, the more practitioners can tick off things we talked about on the Electronic Medical Record (meaning the doctor’s eyes are on the medical record and not the patient) the better. If reimbursement goes down then patient numbers have to increase – meaning more time in front of the computer ticking off the boxes to get paid for a patient visit. We call that the “EMR computer game “- more patients, more time in front of the computer screen, and more clicks which translates to an increasing complexity of the visit which means more reimbursement.
The problem with loading a clinic with patients, where the objective is winning the EMR computer game, is burnout. Your time becomes devoted not to the person. There is no evidence that the more people you see the better your outcomes will be for the population you serve.
Steve Tierney, is a family practitioner started his career in the United States Commission Corps and now works for SouthCentral Foundation has studied physician burnout:
“When we look at our primary care doctors, I can tell who is going to burn-out and who is going to be happy. The optimal number of customer-owners to see is 14. Those doctors who see sixty patients in a day are headed to burn out. Part of our job is to teach them to slow down, get to know the patient, remove the obstacles from the work flow so they can spend time with their patient.”
– Steve Tierney, MD interview
What We did
In 1998 Southcentral Foundation assumed full management of the entire primary care system for Anchorage Area Alaska Natives.
For fifty years the outpatient needs of our people were taken care of at the Alaska Native Medical Center through the Commissioned Corp of the Indian Health Service. They were not taken care of terribly well. In 1998 Southcentral Foundation took control of the healthcare system because of an act of Congress, called the Indian Self Determination and Education Assistance Act. The Act (called title 638) allowed our tribal organizations to acquire control over the management of our primary healthcare system.
One of the prime examples is what happened with children. Children can either have a great experience with their doctors, or a poor one. In the days of the “Native hospital” the kids would see a doctor in the emergency department.
“As a child, I grew up going to the emergency department of ANS – or the ‘Native hospital’ as we called it – for all of my health needs. This meant checking in and sitting among numerous other people waiting with one of my parents every time I had strep throat, an infection or an annual sports physical. This was my norm from early childhood through college.”
“It was a painful process – physically and mentally. Here I was feeling ill and lousy and having to bare the anguish of not knowing when I’d be fortunate enough to be called to move to an exam room and actually be seen. It was extremely uncomfortable waiting on hard plastic chairs, if a chair was even available. We were a generation without portable electronics and the joy of entertainment-on-demand.”
“Once ushered to a room, the wait would often just continue. And depending on the prognosis, we’d have to walk long, gloomy halls to lab, x-ray or the pharmacy as the steps to wellness just kept prolonging the agony. It was truly a miserable experience, and one that I fretted each and every time. “
“But this is how I knew health care. It left me wondering why my family didn’t have our own Marcus Welby, M.D. It made me coveting my own Dr. Welby and the notion of house calls. What joy not having to start from scratch with a new medical professional each time I was sick. What joy not having my several-inches-thick medical file combed through for history. Oh how novel to be comforted and put at ease when feeling sick.”
How healthcare changed is seen through this same mother who takes her daughter to see her doctor at the primary care building.
“Now 40-plus years later, I am fortunate that my 7-year-old daughter welcomes a visit with her primary care provider. I smile to myself knowing she has her own Dr. Welby that has seen her since she was just weeks old. And it makes me feel comforted when she asks questions and engages in banter with her favored doctor. She has grown up not to be afraid but to embrace health care. She has grown up looking forward to her school physical and even a flu shot. She is growing up focused on wellness and not the dread of being sick.”
“How endearing it is when Dr. Browner refers to her as Ms. Ella; when he shares, and even repeats, the names of the instruments; and when he asks her funny questions to test her development in such a natural manner completely unbeknownst to her.”
“It makes me proud as a mom, and it makes me proud as a customer-owner. We now have a health care system our Alaska Native people own and have helped shape from the broken system of my youth. Not only is there a Dr. Welby, but there is a full, integrated team. In addition to our provider, we have a case manager, case management support, a dietitian, a behavioral health consultant and a pharmacist.”
“Here is the relationship with a focus on wellness of my childhood dreams.”
– Allison Knox – interview
We assumed responsibility for the healthcare of 65,000 Alaska Native and American Indian people living in Anchorage, Matanuska-Susitna Valley and 55 rural villages. The area we cover is roughly the size of Sweden.
We Changed Their Culture to Our Culture
Overnight our organization inherited physicians, support staff, and a building. We also inherited a culture, a culture of seeing lots of people through the outpatient clinic. It was time to change that culture. So the first thing we did was change the term “patient” to customer-owner. It was now their system, not the paternalistic system from the Federal Government that was doing things “to them.” They owned it, and when they come to the facility they own it, and what is done is a collaboration. To hear Katherine Gottlieb talk about it – this was revolutionary:
“I thought it would be a good idea. And the reason is because when I showed up to Nordstrom and I was customer six of you would be showing up to me and asking me what you could do to help because I was your customer.
There’s a different feeling that happens if you’re a consumer rather than being patients. And the bureaucracy and the crazy feeling of the government way of operation right now how they looked at us you have to add the prejudice, even if we don’t want to talk about it.
In the villages when the nurses and the doctors came to visit us, it always felt they were white coats. They were up here and we were down here and they were treating us, saving us. So we needed a paradigm shift. Maybe if we were called customers and even stronger “customer owners” a paradigm shift might happen and it did.” – Katherine Gottleib, interview
The old hospital- great in its day. Now the new hospital with the primary care campus. The new hospital is smaller, but now primary care has added over 300,000 sq feet of space for our customer-owners
We asked our customer-owners a lot of questions. Such as, what is the thing you want to change? The first thing was the wait times for the outpatient. The second was they wanted their own doctor. Not a new doctor every time they went to clinic.
We knew we were revolutionizing our healthcare system, and so we named this system of healthcare NUKA. NUKA is an Alaskan term of endearment used to describe large and living things. Like polar bears and enormous mountains. In this case, it was our healthcare system for our customer-owners.
Relationship Based Medicine
Recognizing that customer-owners are in control of their health, the Nuka System of Care focuses on their journey, and on the influencers for their healthcare.
That means you get to know your physician, they know you. Your physician is a part of a team that includes a case manager (to field calls, make arrangements) a behaviorist (because sometimes you need to talk to someone – and we find a lot) a nurse and then there are many other surrounding members to come in and help.
My doctor Steve Tierney reassuring me I wasn’t going to die, but I could stand to walk a bit more.
I experienced that first hand. I had spent the two weeks with a worsening cough. For the last few nights my cough was so bad that I was sleeping upright in bed. I knew my allergies were acting up, but this was more than I had ever encountered. On my way to Alaska I asked if my doctor, Steve, could see me. Steve met me in a hallway between meetings. I was convinced that I had developed heart failure, which is why I was sleeping upright, or perhaps worse. Within minutes he had diagnosed my worsening allergies, had given me three prescriptions to overcome them, and then asked “So, what else is going on with you.” Access to my primary care physician that day, immediate prescriptions (with no co-pay or deductible), and time to discuss what else was going on in my life, besides allergies in Phoenix, that might be making things worse. There was no hurry to get to another patient, it was relaxed, comfortable, and easy. In that he reassured me, “Terry, it isn’t lung cancer, and you don’t have heart failure, and you will live to see your son grow up.” He then spent the next twenty minutes talking with me about eating and exercise, and things to do. Yes, I do need to walk more (in case you were asking). When we talk about influencers in our life, clearly he knew my son was one of them.
Keeping People Out of the Hospital
The most expensive place to treat patients is a hospital. Taking care of a patient before a hospital is one of the best ways to decrease costs. One of the prime examples is what happened with childhood asthma.
Prior to the government turning over the outpatient healthcare to Alaska Natives children who had asthma would end up in the emergency room and often end up being admitted for an acute exacerbation of asthma. Today, rates of admission for childhood asthma are down over forty per cent. The customer-owner being able to talk with the primary care physician, learn how to use their medicines, and the ability to see the primary care physician that day helps. But more important is the relationship that the primary care provider (or pediatrician, since they are a part of this system) have with the parent as well as the child. No child wants to take medicine, but when they do they feel better, perform better in school, have less issues with getting out of control. Having a relationship with the parent means you can talk with them more about smoking cessation, and smoking in the home. Our system also has reduced the barriers to the customer owner who wants to go to a smoking cessation program – you don’t have to see the doctor first to go there, you can just go there.
Besides the large healthcare cost of admitting a patient, or a patient utilizing an emergency room for their care, there is the more human side. There is no parent who wants to visit their child in the hospital. The human cost of having a child in the hospital with an exacerbation of asthma is large. It means parents often have to take time off work, find someone to take care of other children, and it is difficult for children to sleep in strange places.
When the first hospital was built in 1953 patients might stay in the hospital for weeks if not months. That was how medicine was done then. It was more convenient for the physician to have the patient in the hospital. In fact, hospitals were originally designed for the convenience of the physcian – keep everyone in one place, make rounds in one place.
There is no upside to keeping someone in the hospital longer than they need to be. There is no utility in “monitoring” the patient. Keeping patients in the hospital longer increases the risk of severe hospital-acquired infections – and those are often resistant to antibiotics. Keeping patients in the hospital increases the risk of hospital mistakes that can lead to further complications and “hospital error.”
The system that was set up for Alaska Natives from 1953 was a hospital-centered, physician centered, government bureaucratic system that was not satisfying to patients, increased physician burn-out, and yet was considered to be “the culture” of the system.
We had to change the culture. And we changed that culture, by using our culture.