Transforming the health of Native Alaskans
Southcentral Foundation (SCF) provides healthcare for 55,000 Native Alaskan people. It was four years old as an entity in 1987 when Katherine Gottlieb, just 22, walked into the shabby office to take up her new job as the receptionist. “One of the first things I did was replace the dinged-up old metal reception desk with a nice oak one, and started dressing nice,” she says. She felt it was time to show more respect toward her people, who at the time were being poorly served.
Her community (she is half Aleut) was suffering due to a confluence of broader cultural changes. The loss of traditional ways of life, including warrior traditions and fishing as a livelihood, had disrupted native culture to the point where depression and stress among the tribes were at high levels. Obesity, alcoholism, diabetes, and violence against women were on the rise, with little hope for improvement. This, Gottlieb says with understatement, was hard to watch.
She worked to understand every aspect of how the foundation ran. Remarkably, within four years she was the President and CEO, with an ambitious new agenda. Under a new deal with the government, SCF had agreed to take on more responsibility for health outcomes, and to shift from a fee-per-treatment system to a fixed sum per person. While this deal gave SCF the impetus and freedom to innovate, it also brought with it a pressure to change: with healthcare costs spiralling across the United States on the one hand, and a local population with growing needs on the other, Gottlieb had to become very ambitious in the face of some big constraints. Her propelling question was as challenging as any: “How can we dramatically improve the health outcomes of a community that is highly disenfranchised?” In the same people she wanted to help were the roots of the very constraints she would need to embrace.
That embrace began with six months of deep listening. The first epiphany to come out of this was that SCF had been treating symptoms, not people. By their reckoning, 75–85 percent of all healthcare expenditures were related to long-term lifestyle factors of the patient. If SCF were to improve the health outcomes of the community, they would need to tackle an entire system of constraints surrounding their people’s current relationship with their lifestyle and culture.
The first can-if reflected this shift in focus: they would redesign their system around the whole person “and their messy, human, longitudinal, personal, trusting, informing, respecting, and accountable relationships.”8 They called this the Nuka system of care (“nuka” is a native word meaning strong living things) and it would address the lifestyle and cultural causes of illness—a hugely ambitious mission, requiring the implementation of multiple initiatives over a decade.
At the outset, Gottlieb’s team faced a host of apparently impassable obstacles: treating the whole person would take a level of time and effort that they couldn’t afford, requiring specialists they didn’t have, deploying a cultural sensitivity they’d need to develop, among people who might well resist it even if it could be implemented in this way. Just think about the perseverance it would have taken for Gottlieb and her team to push through the doubts and skepticism they encountered.
The second can-if had to do with the nature of the core relationship between SCF and their patients, and the language used to describe it: the Nuka system would change patients into customer-owners. As customers, the community would expect high-end service by the staff, which would be accountable for it; and as owners, people would be in charge of both their own health outcomes and the system itself, redesigning it to meet their needs. This language shift, and the relationship it embodied, forced changes to both the services offered and the behaviors of the people in the system. While healthcare professionals recommend prevention and treatment options, the customer-owners take responsibility for choosing what’s best for them, and learn to see themselves not as victims of an imposed system, but as people in control of their own future—and in doing so, change the story they tell themselves about their ability to influence their situation.
The next can-if was to set up integrated care teams to treat the whole person: tribal doctors, traditional healers, acupuncturists, massage therapists, and psychologists were integrated with conventional medical staff for the first time—a considerable feat in itself. A new hospital was then built around a radically different floor plan and operating procedure. Everyone was asked to give up their offices to create collaborative workspaces and talking rooms to meet with the customer-owners in teams, and all of this coordinated by a nurse, whom the customer-owner could call directly. They would build real trust between SCF and their customer-owners by removing barriers of space, attitude, language, and time, with an 80 percent ability to deliver same-day access. Enabling systems were put in place, staff retrained, and performance data shared widely to create accountability across the system.
While all of these moves were difficult to plan and complete, reaching into the community to address the highly sensitive cultural issues affecting healthcare was when Gottlieb had to be at her most creative and tenacious. She initially failed, for example, to persuade native leaders to support a project tackling the issue of child sexual abuse: they were not even prepared to have the conversation. In the end, Gottlieb’s winning can-if was to reframe the role of the warrior in native culture, and ultimately create the Family Wellness Warriors Initiative, one of her favorite projects:
This time, I said “I need you as tribal men like you were in the old days, when you were willing to risk your lives for your wives and children and willing to step forward to defend and protect us.” You could feel it—everything changed. They said, “What do you need?”
Taking the constraint—a disenfranchised community, with no motivation or sense of control over their own lives—and resisting the temptation to simply neutralize it, but rather make it the stimulus to a series of transformational programs, has generated extraordinary results. Customer-owner satisfaction levels are at 91 percent; wait lists have fallen from 1,300 to almost zero; urgent care and emergency room visits are down 40 percent due to the same-day access system, saving millions of dollars. Treatment quality has measurably increased, and third-party assessments show the staff are happy, knowing they are making a difference. Southcentral has been able to do all of this on a budget that increases just 2 percent a year while their customer-owner number grows at 7 percent a year. In 2011, the U.S. Commerce department awarded Southcentral the prestigious Baldridge Award to honor the scale and nature of their success.
Though young, Gottlieb had ensured she was well-qualified for the challenges of SCF. She had made time to study for her MBA early in her role as CEO, and was disciplined in combining the tools of modern management with creating an environment in which native people would feel more comfortable. Her relentless focus on survey data and accountability leaves no one in any doubt about what matters, and total transparency ensures that underperformers know who they are and how long they have to pull their socks up.
But that’s not the whole story. The personal commitment that this twenty-five year journey demanded comes partly from her background. She’s half Aleut herself, with roots in the community whose plight was once very much her own. Her mother was an alcoholic; she herself was pregnant at sixteen and fled an abusive first husband; few challenges faze her after that. It would be too glib to attribute Gottlieb’s success, or that of any other person who triumphs over a difficult past, to a theory of “desirable difficulties” (the notion that there can be advantages in disadvantage). But Gottlieb’s struggles clearly made her who she is, and she channels all the emotional intensity and toughness acquired into setting a high bar, finding solutions in her constraints, and making those solutions happen when others might blanch.
If this strong emotional connection is so important to success, then are there particular kinds of emotion that seem to be especially important? And, if so, how do we tap into them and draw from their strength?
