Tracee Te Huia was fustrated.
As general manager of Maori Health at Hawke’s Bay District Health Board, she said, “I couldn’t understand it. We have integrated teams, committed staff, and great leaders. We are working hard to form strong partnerships within our communities, and yet we are still struggling to get on top of some persistent health issues.”
In 2015, Te Huia and other health executives from around the world were invited to Alaska to learn how the Southcentral Foundation (SCF) developed a highly successful, internationally renowned, tribally managed health care system called the “Nuka System of Care” – ‘Nuka’ is an Alaska Native word for strong, giant structures and living things.
The Nuka System of Care is managed and owned by Alaska Native people. Te Huia said, “I felt honoured to be invited and have the opportunity to learn from Alaska. The similarities were striking between us in Hawke’s Bay and when they first introduced the new system in 1982. Back then they were experiencing alarming rates of diabetes, child abuse, mental illness, domestic violence and increased presentations in the Emergency Department. I felt we could learn from them.”
SCF is a nonprofit health care organisation that manages services for 229 federally recognised tribes serving around 65,000 Alaska Native and American Indian people living in Anchorage, Matanuska- Susitua Valley, and 55 rural villages. It is recognised as one of the world’s leading models of health care redesign. The system is based on a whole care or ‘wrap around’ approach where departments and programmes work interconnected with each other and the community, in order to achieve physical, mental, emotional, and spiritual wellness of the people.
Much of their success is attributed to the change of ownership from a bureaucratic, centrally controlled system, to self-determined, customer-ownership. With this change, Alaska Native People were put fi rmly in the driver’s seat for all the decisions and administration. The responsibility of caring for their people became solely theirs. This initiated a complete redesign of health care delivery, philosophy and values. Starting with an operating budget of $3 million ($US) and a sta of 25, three decades on they have grown these fi gures to $210 million ($US) and a workforce of 1,500.
What do they do differently?
Tracee comments, “The Nuka System of Care is built around meeting the needs of the customer-owners. The customers are equals. The system is based on three basic beliefs – Customer Ownership, Relationships and Whole System Transformation. There is a sharing of power between the doctor and the customer, allowing the customer to have complete ownership of their own health. The customer is assigned to a primary care team made up of a doctor, a nurse, behavioural experts and an administrator. The philosophy is one of collective responsibility shared between the specialists and the customer.”
The Nuka System of Care did not simply spring from the ground; with ownership came a sense of autonomy that freed them to be innovative, creative, and truly address the real challenges of their people. They initiated an aggressive campaign to find out what their customer-owners needed to enable them to take charge of their own lives. These findings became the blueprint of a system that prioritised the needs and values of the community. The research also highlighted low sta morale, high sta turnover, and a general feeling of ‘us versus them’.
Tracee continued, “importantly it is not just the customers this system focuses on; it has a strong emphasis on the wellness and development of its employees. Wellness is literally lived throughout the staff, they all know one another’s unique ‘stories’. This is carried on through to the customers.”
SCF places high value on building, and nurturing strong, effective relationships among the employees. Through a culture based on trust, SCF goals, objectives, and work plans – across the organisation – are efficiently accomplished. This element of trust is demonstrated to the sta from the executive leaders. The leaders are required to share personal experiences, actively invite discussion and questions, openly admit mistakes, and celebrate successes. All new employees attend a three-day mandatory core training lead by the CEO.
Te Huia commented “many of the employees are Alaska Native and American Indian customer-owners, this includes 60% of their management staff, and both clinical and non-clinical roles. The board of directors and advisory board members are solely comprised from customer-owners – the organisation is literally a microcosm of its community. This results in a better understanding of what the customer really needs to create positive and long-term change in their lives. Ultimately this has an effect on the use of resources, as people, and their families, stay well.”
SCF is well-known for its accountability. Their commitment to performance measurement and utilization of data has won them international awards. SCF feel this commitment has played a huge role in the continuing successes of their organisation. In 2003 SCF established the SCF Data Mall. This enabled front line employees to access aggregate and individual data. Individuals and primary health teams can compare their performance against their peers, and nationally-accepted bench marks. Access to the higher performing employees and teams, supported with training, has resulted in tremendous gains across the organisation.
Te Huia realised that there is a problem within our system. She came to the awareness that the answers to the persistent health problems lie within our own whanau and how HBDHB operates, and communicates with both its employees and the community. In an attempt to address this DHB has developed its own Transform and Sustain initiatives that incorporate some of SCF’s values.
A big part of this initiative is customer engagement. An example of this is the Partnership Advisory Group (P.A.G). P.A.G works hand in hand with mental health services. They are a group of volunteers who speak with lived mental health experiences. They had valuable input into the redesign of the new inpatient Mental Health Unit – Nga Rau Rakau – and services.
Debra Grace, chairperson of P.A.G, said, “While I admire the intentions of the mental health policies and the new initiatives, we have a long way to go before we can achieve what our Alaskan friends have. All DHB employees wear core values on ID lanyards that sit next to their hearts every day. However, there is still a corporate disconnect from Joe public”.
“P.A.G is a good example of how customers can have an influence on services. The structure is all there. But sometimes the great intentions of management do not get through the layers, to the people on the wards, therefore the patient misses out. I do believe the answers are on our own door step. Just ask the right questions of the right people.”
The Nuka System of Care was developed through a change of ownership, listening to the people, and prioritising the needs of those people. Words became actions. Tracee is confident HBDHB can incorporate some of the learnings from Alaska and greatly improve services. But, with three decades on us, we have a long way to go.