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
3
(No Transcript)
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 isnt 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
• Whats 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

• Were 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 wasnt the community!
15
A possible affair ????

• If he is afraid hell lose you, hell 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 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 youve 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)
And divorce was not an option!

• Kim Horowitz, MD
• Owner, Sierra Family Care
• Physician Leader AHRQ Planning and
  Implementation Grants

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
Dont 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

Its your community.your future..your
patients. You can do this!!!!!
21
Who moved my cheese?????
22
Refreeze Living Happily Ever After
Its about creating an environment of integrity
Its about the people and were 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 cant change otherswe 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 isnt 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