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

1. “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 Conference September 26, 2007

2. Who we are Rural Medical Service Study Areas Frontier – less than 7 persons per square mile Rural – less than 250 persons per square mile Non-Rural 80% of land mass 14% (and growing) of population live in rural California 4.9 million residents Source: 2000 census data

4. Scope of our Project • Infrastructure • Telemedicine • EHRs and CHIE • PHRs • Diabetes Education • Health professions training

5. 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

6. Theories • Unfreeze, Change, Refreeze (Lewin, 1953) Yawn…..

7. Culture change? Or marriage counseling? • Unfreeze – The Marriage isn’t working • Change – Focusing on oneself • Refreeze – New ways of relating to each other

8. 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?

9. 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

10. 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

11. 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

12. Unfreezing the Culture “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” Jami Young, MPA Assistant Administrator, Tehachapi Valley Healthcare District and Project Coordinator, AHRQ grant

13. 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

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

15. A possible affair ???? • If “he” is afraid he’ll lose you, he’ll change • Uh-oh…. “he” has already lost us • Move the grant?

16. The pain becomes too great

17. You have to be willing to create an environment in which the status quobecomes 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)

18. Change: Creating New Ways of Doing Things 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) Kim Horowitz, MD Owner, Sierra Family Care Physician Leader – AHRQ Planning and Implementation Grants And divorce was not an option!

19. 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

20. 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!!!!!

21. Who moved my cheese?????

22. Refreeze: Living Happily Ever After “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” Rex Moen President East Kern County Integrated Technology Association (“EKCITA”)

23. Refreeze

24. We can’t change others…we can only change ourselves And they did!! Creating a new way of relating • Structure • Communication • Vision • Purpose • People

25. Before….no infrastructure to facilitate information technology, quality or disease management Big Dot!!!! Hospital and RHCs Providers Negotiation leverage Return on Investment Presence of consistent and coordinated community oriented approach ??? X X X X X X X Workforce Development Evidence Based Medicine Acquisition and Dissemination of information technology Continuing Education Practice Management Support Research Community Based Quality Improvement Programs and Monitoring

26. Building infrastructure to address the quality chasm in Rural Communities Provider leadership team No longer hospital centric Governance EAST KERN COUNTY INTEGRATED TECHNOLOGY ASSOCIATION “EKCITA” (a 501(c)3 public benefit corporation) Providers in SE Kern Hospital and RHCs Consistent, Coordinated, Integrated, Community Approach to Health Workforce Development Evidence Based Medicine Acquisition and Dissemination of information technology Continuing Education Practice Management Support Research Community Based Quality Improvement Programs and Monitoring

27. How many psychologists does it take to change a light bulb? None – the light bulb has to really want to change.

28. Lessons to Share • 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!!!

29. 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.

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