# Presentation: 040724

## “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 3****rd**** Annual Conference**
**September 26, 2007**

## Who we are

**80% of land mass **
**14% (and growing) of population **
**live in rural California**
**4.9 million residents**
- Source: 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**

**Notes:**

In fact, 80% of California’s land mass is rural

When you look at the Inland Empire, easily half is frontier (7 people per square mile), and most of the rest is rural (less than 250 per square mile).  Only a very small portion is urban.
And rural is growing  - not because of the overall growth in population in california, but because of
Dynamic of “equity refugees” – people in urban areas who sell their homes, cash in their equity, and move to a more tranquil life in rural regions. And yet, those same people expect amenities, such as healthcare, at the same level of access and quality as in urban regions.

And rural Inland Empire is changing too.

## Slide 3

## 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, MPA**
**Assistant 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, MD**
**Owner, Sierra Family Care**
**Physician 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**

## X

**Providers**

**Hospital and RHCs**

***Acquisition and Dissemination of information technology***

***Community Based Quality Improvement Programs             and Monitoring***

***Continuing Education***

***Research***

***Practice Management Support***

***Evidence Based Medicine***

***Workforce Development***

- Before....no infrastructure to facilitate information technology, quality or disease management

- Negotiation leverage
- Return on Investment

- Presence of consistent and coordinated community oriented approach ???

**Big Dot!!!!**

## Consistent, Coordinated, Integrated, Community Approach to Health

***ASSOCIATION***
**“****EKCITA”**
- (a 501(c)3 public benefit corporation)

**Providers in SE Kern**

**Hospital and RHCs**

***Acquisition and Dissemination of information technology***

- Provider leadership team

- Governance

***Community Based Quality Improvement Programs             and Monitoring***

***Continuing Education***

***Research***

***Practice Management Support***

***Evidence Based Medicine***

***Workforce Development***

- 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!!!

**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