“For Better or For Worse”…. A case study in culture change

Kiki C. Nocella, PhD, MHA(With… Jami Young, Dr. Kim Horowitz, and Rex Moen!!)AHRQ 3rd Annual ConferenceSeptember 26, 2007

80% of land mass 14% (and growing) of population live in rural California

4.9 million residentsSource: 2000 census data

Rural Medical Service Study Areas

Frontier – less than 7 persons per square mile

Rural – less than 250 persons per square mile

Non-Rural

Who we are

Scope of our Project• Infrastructure

• Telemedicine

• EHRs and CHIE

• PHRs

• Diabetes Education

• Health professions training

Status of IT in the Region - 2005• Approximately 17 primary care physicians

and 7 midlevels in 17 sites in 4 towns• Various stages of IT adoptions

– Some with no computerized practice management systems

– Some without internet access– No customized databases

• One with an EHR– No data exchange occurring– System not being used for reporting

• Hospital with multiple systems at different levels of functionality and not interfaced

Theories• Unfreeze, Change, Refreeze

(Lewin, 1953)

Yawn…..

Culture change? Or marriage counseling?

• Unfreeze – The Marriage isn’t working

• Change – Focusing on oneself

• Refreeze – New ways of relating to each other

Overview – Phases of “Marriage”• Courtship and Engagement and

Marriage

• In good times and in bad

• Separate bedrooms

• Marriage Counseling

• A possible affair

• And then the pain became too great

• Creating new ways of doing things

• Will they live happily ever after?

Courtship, Engagement, and Marriage•24 bed Critical Access Hospital

–2 rural health clinics, growing to three–District hospital with an elected board

•17 physicians in private practices throughout a 4 town region

In good times and in bad• Sometimes the hospital partnered

with community physicians to recruit more physicians, develop initial RHC, etc.

• Sometimes the hospital competed with the local physicians

• Administrators in, administrators out, but doctors and hospital remained.

Over time, challenges with communication led to anger and

distrust

Separate Bedrooms• State of the “union” when grant

came to town• Hospital with 1.3% market share• No trust• No one willing to be vulnerable• “What’s in it for me?”• No one moving in the same direction• “Hospital centric perspective”….

“the tail wagging the dog” And yet you need trust and collaboration to share data

Unfreezing the Culture

Jami Young, MPAAssistant Administrator, Tehachapi Valley Healthcare District and Project Coordinator, AHRQ grant

“Doctors and Hospital Administration had gotten into a habit of working in isolation of each other”

“We initially took an approach of education and facilitating conversation and collaboration. But in the end, it took the “Big Bang” approach to Un-Freeze”

How to Unfreeze - Marriage Counseling• We’re trying to “unfreeze” the culture

– In marriages – you might try:• Counseling• Taking a class• Learning to communicate

• For culture change?• Introducing a new opportunity

– A grant?– Required collaboration and participation – This became a mantra for that which was

absence – and a focus for local politics

Is it working for you?

‘ Cause it has to be working for someone!!!...AND that wasn’t the community!

A possible affair ????• If “he” is afraid he’ll lose you, he’ll

change– Uh-oh…. “he” has already lost us

• Move the grant?

The pain becomes too great

You have to be willing to create an environment in which the status quo becomes more painful than the experience of positive change

There is a time when the operation of the machine becomes so odious -- makes you so sick at heart that you cannot take part. You cannot even passively take part. And you’ve got to put your bodies on the gears and upon the wheels and levers, upon all of the apparatus and you have to make it stop and you have got to indicate to the people who run and own it, that unless you are free, the machine will be prevented from working at all. (Mario Savio, UC Berkeley free speech activist, 1964)

Change: Creating New Ways of Doing Things

Kim Horowitz, MDOwner, Sierra Family CarePhysician Leader – AHRQ Planning and Implementation Grants

Change is difficult!!!!!!

“I feel like we have commenced to take care of the rat problem aboard ship by setting fire to the hold. The only problem is, land is no where in sight….”(email to K. Nocella from K. Horowitz; June 11, 2006)

And divorce was not an option!

What your therapist my say….• Move from blaming others to

focusing on ourselves

• Be strong and clear in your identity

• You are not powerless– Owning your power

Or…..find a buddy and fight the windmills

Don’t give up"The sea rises, the light fails, lovers cling to

each other, and children cling to us. The moment we cease to hold each other, the moment we break faith with one another, the sea engulfs us and the light goes out."  James Arthur Baldwin

It’s your community….your future…..your patients.

You can do this!!!!!

Who moved my cheese?????

Refreeze: Living Happily Ever After

Rex Moen

President

East Kern County Integrated Technology Association (“EKCITA”)

“It’s about creating an environment of integrity”

“It’s about the people – and we’re fortunate to have developed a group of people who want to, and do, make a difference”

Refreeze

We can’t change others…we can only change ourselves

And they did!!

Creating a new way of relating

• Structure• Communication• Vision• Purpose• People

Providers Hospital and RHCs

Acquisition and

Dissemination of

information technology

Comm

unity Based Quality

Improvem

ent Programs and

Monitoring

Continuing Education

Research

Practice Management

Support

Evidence Based

Medicine

Workforce

Development

Before….no infrastructure to facilitate information technology, quality or disease Before….no infrastructure to facilitate information technology, quality or disease managementmanagement

Negotiation leverage

Return on Investment

X

Presence of consistent and coordinated community oriented approach ???

X X X X X X

Big Dot!!!!

EAST KERN COUNTY INTEGRATED TECHNOLOGYASSOCIATION

“EKCITA”(a 501(c)3 public benefit corporation)Providers in

SE KernHospital and RHCs

Acquisition and

Dissemination of

information technology

Provider leadership team

Governance

Comm

unity Based Quality

Improvem

ent Programs and

Monitoring

Continuing Education

Research

Practice Management

Support

Evidence Based

Medicine

Workforce

Development

Building infrastructure to address the quality chasm in Rural Communities Building infrastructure to address the quality chasm in Rural Communities

Consistent, Coordinated, Integrated, Community Approach to Health

No longer hospital centric

How many psychologists does it take to change a light bulb?

None – the light bulb has to really want to change.

• Need to pick a community that is so in pain they are ready to change– Offer the beads of change– Like the light bulb, they really have to

want to change

• Governance – create a safe place

• Change is challenging …technology isn’t the barrier

• Find a buddy

• Be ready to take some risks….so have your safety net!!!

Lessons to Share

Will they live happily ever after?• Our “Refreeze” is not yet complete

• Risks of Global Warming…..and the tendency to slip back to patterns of old

• However – a lot of new infrastructure, relationships, and people.

This project funded by a grant from the Agency of Healthcare Research and Quality