# Presentation: 656265

## Improving Health with the Director’s Chronic Care Initiative 

**Improving Health with the Director’s *****Chronic Care Initiative***
*NCCD*
- Ty Reidhead

**Notes:**
I am incredibly grateful and honored to be given this time to discuss with you the Director’s Chronic Care Initiative.  

A few months ago I was informed by email that the Surgeon General would not be able to attend the conference, and as a result, I would get to present immediately before Dr. Don Berwick.  I was more than a bit worried.  So, I sent an email to a good friend of mine whose hero is Dr. Berwick.  There was only one possible description for my feelings, “Lord, help me...”

This friend was excited for me and tried to reassure me that “It is always better to go before a great speaker than to follow one.”   

Today, we get to talk about hope.  I believe that it is not just coincidence that it is on Super Tuesday that we get to talk about changes in the Indian Health System.  We hear about hope from candidates running for presidency on the campaign trail, and I am going to talk with you today about hope.

## Prevalence of Diagnosed Diabetes

- Source: IHS Program Statistics and National Diabetes Surveillance System. Age-adjusted to the 2000 US standard population with the exception of 1981–1993 data for AIAN, which was age-adjusted to the 1980 US standard population.

**1980- 2004**

**Prevalence of Diagnosed Diabetes**
**AI/ANs compared to U.S. population**

**Notes:**
Many chronic conditions in the United States have received extensive attention because of their ever increasing prevalence.  When we begin to think about these conditions among the populations that we serve, it is more concerning and difficult to ignore.  The increase in American Indian and Alaska Natives who have diabetes is just one example.

## Care according to guidelines of 10 chronic diseases:
If everyone in the patient panel was “controlled”
3.5 hours per work day
If add some uncontrolled cases
6.7 hours per work day 
Assuming 1,949 hours/year spent in patient care

- If everyone in the patient panel was “controlled”
- 3.5 hours per work day
- If add some uncontrolled cases
- 6.7 hours per work day
- Assuming 1,949 hours/year spent in patient care

*Ann Fam Med 2005*;3(3):209-214

- Is there time for Management of Pts with Chronic Conditions in primary care?

**Notes:**
Unfortunately, we know from studies that have occurred outside of the Indian Health System that there is just not time for the usual care of chronic conditions in primary care clinics.  A study that was published in 2005 highlighted this discrepancy.  They noted that if a provider has a typical patient panel in which the primary care provider is responsible for treating ten standard chronic conditions, that it would require three and a half hours out of every day just to take care of that segment of the patients.  If we add in the fact that a few of those patients have “uncontrolled” chronic conditions, it would increase those estimates to over six and a half hours of every day.  Unfortunately, the populations that we serve have a higher prevalence of many of the conditions that were considered in this study.  If the authors would have performed this study in our populations, they would have found that it would take over nine hours of every day just to take care of patients with these chronic conditions.

## Geographic Isolation

**Notes:**
“Fortunately,” in my book anyway, the Indian Health System provides care to people in rural and frequently isolated settings (I like it that way).  As an example, Whiteriver Service Unit is thirty minutes drive to a hospital with a surgeon and a few specialists, but is over three hours to a large enough city that can provide much of the emergency care that is needed for our patients.  Other IHS facilities that are close to us are in similar situations.  

Despite this geographic isolation, we also tend to isolate ourselves functionally.  Despite the fact that the closest IHS facility is just as isolated geographically as us, we rarely share stories of success or failure in bringing changes to the care of our patients.  I am not sure why this is? I have not been able to figure out if has something to do with the way that physicians are trained, or maybe it is just part of the “not invented here syndrome?”  It must be related to the function of the system somehow, that makes it hard to share... possibly just because we are all too busy to take the time to find out what is going on in neighboring facilities to improve care.  The bottom line is that we are isolated; not just geographically, but functionally.

## International Comparison of Spending on Health, 1980–2004

- Data: OECD Health Data 2005 and 2006.

- Average spending on healthper capita ($US PPP)

**Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006**

**EFFICIENCY**

**58**

**Notes:**
Unfortunately, when we look at the appropriations for delivering care to American Indians and Alaska Natives, there is a wide gap when compared with the US “Health System.” 

## Slide 6

**Notes:**
Even without considering all of the other challenges that face the Indian Health System, it would be difficult to find much hope.  In fact, I would submit that there are two possibilities: either we are utter fools, or we have something or know something that the rest of the US Health System can not.

## The Healthcare System Hope

**Notes:**
Lets start with a picture... it is a picture of my hope.  This is my youngest girl, Aubrey.  When I look at this picture, it is easy to be hopeful, even if I am a fool.

About a month ago, Aubrey got sick.  She had a horrible Gastroenteritis.  With it, we knew that the fevers and vomitting were just a part of it.  About two days in, it was my turn to stay home and take care of her so that my wife could get to work to take care of her patients.  Unfortunately, that was not to be, because for that day, I can attest to the fact that this was a horrible GE, as it pinned me to the bathroom for twenty four hours.  

After Aubrey had suffered at the hands of this non-stop GE for about 7 days, it had become easy to see that she had lost almost two pounds... and two out of 20 is a lot of weight.  Some of it was dehydration, but much was just being ill.  Well, it so happened that that it was my day again to watch her.  By the end of the day, I realized that I couldn’t really say if she had peed at all through the day, and I was worried.  This is where it is not good to be an internist.  All of the horrible diagnoses, especially the zebras, begin to run around inside my head.  “Could she be going into renal failure?  I wonder what her bicarb is? When we force her to drink, she does seem to act better... but could she be going into renal failure?  Does she have salmonella?”  Bottom line was that I was worried.

What do you think I did? My beautiful little girl looked nothing like this by this time.  What were my options?

I could go to the ER.  I could wait until tomorrow and worry all night that I am doing the right thing... What did I do?

Of course, my best friend is a pediatrician.  Of course, I pulled this ace and called him at home.  My friend was happy to take my call and reassure me that she would be better and that I needed to force feed her more Enfalyte until she peed.

What do our patients do?  
Sorry, they have one option... they go to the ER. 

## Crossing the Quality ChasmExecutive Summary

- “The *American* health care delivery system is in need of fundamental change... care delivered is not, essentially, the care we should receive... frustration levels... have... never been higher... Health care harms... and routinely fails to deliver its potential benefits.”

**Notes:**
Interestingly, the Institute of Medicine in “Crossing the Quality Chasm” noted in 2002 that “The American health care delivery system is in need of fundamental change... care delivered is not, essentially, the care we should receive... frustration levels... have... never been higher... Health care harms... and routinely fails to deliver its potential benefits.”  So, maybe quality health care is not just a function of how much money is spent on it.  After all, the US Health System is spending three times as much money as the Indian Health System and still receives such bighting criticism.

## Care Model

**Informed,**
**Empowered Patient and Family**

- Productive Interactions** **through effective asset based partnering over time

**Prepared,**
**Proactive**
**Practice Team**

**Improved achievement of patient and community goals**

**Delivery****System**
**Design**

**Decision**
**Support **

** ****Clinical****Information****Systems**

**Self-****Management ****Support**

**Health System**

**Resources and Policies**

**Community **

**Health Care Organization**

**Care Model**

**Patient**** ****Driven**** **

**Coordinated**

**Timely and Efficient**

**Evidence-based and Safe**

**Notes:**
In response to this report, Dr. Ed Wagner of the MacColl Institute for Improving Chronic Illness Care added five of the six elements that the IOM suggested would improve the health care system to his “Chronic Care Model.”  The Chronic Care Model is a model for a system of care that has the real potential to achieve Patient Goals.  The five elements for improvement that were added are patient-centered, timely, efficient, safe, and effective. 

Dr. Wagner left one of the six IOM Aims for Improvement of the Healthcare System out of his model. 

## IOM’s 6th Aim

- Equity –
*Freedom from bias or favoritism*
- Equitable –
*Dealing fairly and equally with all concerned *

- _[www.m-w.com/dictionary](http://www.m-w.com/dictionary)__ _*Merriam-Webster’s Online Dictionary*

**Notes:**
The excluded Aim is equity.  Why was that left out?
Perhaps because if we really can provide care that is safe, effective, patient-centered, timely and efficient, through a relationship between an informed activated patient and a prepared proactive care team, then it would have to be equitable?  Perhaps it is hard to fit equity into a model?
It is unclear to me how to fit equity into the Care Model.
I do know that we have a special challenge in achieving a system that provides equitable care.  If we are going to do so, we have to intentionally create a system that provides care where I would not only want my patients to be seen, but where I would be comfortable with my family being seen, and where I would want to receive my care.

## The Healthcare System for

*“**The care I need and want, when I need and want it!”*

*my patients, my family, and for me*

**Notes:**
This brings me to my first real lesson that I have learned over the last year.  In the beginning of this Initiative, I was reluctant to include words that express this equity.  I did not want to suggest that we want to create a system of care that delivers “The care I need and want, when I need and want it.”  

I now realize that this is what we need and want from our health care system, even if we can’t afford it.

## International Comparison of Spending on Health, 1980–2004

- Data: OECD Health Data 2005 and 2006.

- Average spending on healthper capita ($US PPP)

**Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006**

**EFFICIENCY**

**58**

**Notes:**
Fortunately for us, we are not alone in the financial predicament in which we find ourselves.  Every other developed country in the world has similar expenditures as the Indian Health System.  I understand that this is probably not a fair comparison, as we must purchase some of the care for our patients from providers and hospitals outside of our system.  As such, we don’t get the same returns for our expenditure as we might if we provided care in another country, but at least the company of other more successful health care systems gives me some hope.

## Optimism

**&**
** ****Islands of Innovation**

**“****The Energy of Few”**
** ****The Champions**

***“******Past performance is no guarantee of future results”****** ***

**Notes:**
Two years ago when we started down this path of looking toward how we might improve the care of our patients with chronic conditions and prevent those conditions, we were optimistic.  This optimism was based on the fact that we were “champions.”  We all know champions.  Just look around this room, it is full of champions, else you would not have risen to your current positions.  We also know the sites.  We know the places where champions have made a difference.  We have to believe that we can champion improvement, or we would not even try.  And, we have seen the results of the strong work of champions... we find pockets of excellence and islands of innovation.  Unfortunately, when the champion leaves, the improvement tends to go with ‘em.  The saying that we see on every mutual fund that you can invest in carries the familiar phrase, “Past performance is no guarantee of future results.” 

## Hope

** ****Ideas****+ Improvement ****Tools**

**“****The Energy of Many”**

**Reliably high ****quality care**
**Every patient, ****every time, ****everywhere**

**Notes:**
During the IHI National Forum this year, Dr. Berwick spoke of a different idea.  He spoke of “The Energy of Many.”  This Energy is where Real Hope lies.  This is where profound system improvement can occur... where “Reliably high quality care for every patient, every time, everywhere” can happen.  The way that we get to that is through intentional improvement.  It happens through Leadership creating the will to change, through ideas for change, and through intentional improvement through sequential learning.

## IHS Diabetes Care & Outcomes Audit

- Source: IHS National Diabetes
- Program Statistics 1996-2007

**A1C,**

- %

- Mean A1C,
- 1996-2007

- *p<0.0001 comparing mean A1C levels in FY96 and FY07

**year**

**Notes:**
We can have hope that this works.  We have seen through the Division of Diabetes Prevention and Treatment’s success that population based improvement in treatment of at least single conditions and its complications are possible.  The improvements that have occurred in the Mean A1C for our population is unmatched.  You won’t find another system in the world that can show similar numbers.

We can have hope.  We have enough money to improve, we are a system full of champions, and we have seen some success.

## Care Model

**Informed,**
**Empowered Patient and Family**

- Productive Interactions** **through effective asset based partnering over time

**Prepared,**
**Proactive**
**Practice Team**

**Improved achievement of patient and community goals**

**Delivery****System**
**Design**

**Decision**
**Support **

** ****Clinical****Information****Systems**

**Self-****Management ****Support**

**Health System**

**Resources and Policies**

**Community **

**Health Care Organization**

**Care Model**

**Patient**** ****Driven**** **

**Coordinated**

**Timely and Efficient**

**Evidence-based and Safe**

**Notes:**
So, where do the ideas for this improvement come from?
The change ideas for improvement of the system can be found in the Care Model.  The most important piece of the Care Model is at the bottom. 

## Productive Interactions through effective asset based partnering over time

**Informed,**
**Empowered Patient and Family**

- Productive Interactions** **through effective asset based partnering over time

**Prepared,**
**Proactive**
**Practice Team**

**Improved achievement of patient and community goals**

**Patient**** ****Driven**** **

**Coordinated**

**Timely and Efficient**

**Evidence-based and Safe**

**Notes:**
Continuity of care is the essential piece.  It is all about relationships.  Relationships and interactions with patients and families is what will improve the achievement of patient and community goals.  But, it is not just about relationships between patients and care teams, it is also about relationships between members of the care team because this is how we work together better.

## Innovations in Planned Care Collaborative 

| Federal Sites | Tribal Sites |
| --- | --- |
| Albuquerque Service Unit
Chinle Service Unit
Gallup Indian Medical Center
Rapid City Service Unit
Sells Service Unit
Warm Springs Indian Health Center
Whiteriver Service Unit
Wind River Service Unit | Cherokee Nation Health Services
Choctaw Health Center
Eastern Aleutian Tribes
Forest County Potawatomi Health & Wellness Center
Indian Health Council |
|  | Urban Site |
|  | Gerald L. Ignace Indian Health Center |

**Notes:**
In order to make improvements in the care system, the Chronic Care Initiative, 14 months ago, enlisted 14 pilot sites to explore how to do this.  

## Powerful CIS tools for improvement DM Comprehensive Care 

- iCare

**Notes:**
In order to explain this, I want to make sure that you understand how a bundled measure works.  The example for this is the Diabetes Comprehensive Care Measure.  The way this measure works is that if a patient receives all of the components of care (A1C measured, foot exam, nephropathy screen, retinopathy screen, and LDL measured) then they will be counted in the numerator.  If a patient lacks any one of the components, then they will not get counted.  Because this type of measure requires five components to get credit, it must be understood that it is very hard to make significant improvements in this type of measure.

## Improvement is not easy DM Comprehensive Care

**Notes:**
This brings me to another lesson that I learned this year, that improvement is not easy.  You will see from the first run chart that many teams have been able to improve this measure, some substantially.

## What is a Care Team?

- Everybody who is part of the relationship with patients
- Includes people who are not typical partners
- Relationships within the Care Team are essential.

**Notes:**
Many of the providers at the sites will be the first to tell you that improving this measure has occurred because of the work of the care team.  No longer are we talking about the improvements that the provider was able to achieve.  Instead, what can be done by the team.

## What is a Care Team?

- Everybody who is part of the relationship with patients
- Includes people who are not typical partners
- Relationships within the Care Team are essential.

**Notes:**
The next lesson is apparent in the picture of the flags being used in the clinic.  These sorts of flags are used all across the country to help the flow of clinics, but after many PDSA’s and much learning as to how to best use this system and how to orient new members to the team as to how to use it, we were still having difficulty.  Ultimately, it was a member of the care team and not the physician who had the “profound” idea to label the flags.  Viola, no orientation needed.  The system functions without orientation and will spread easily.

## 
“I’ve worked here for 2 years and this is the first time I feel like I’m part of something...  I’m part of a team, and we’re working to make things better.”
- Information Resource Management 

- “I’ve worked here for 2 years and this is the first time I feel like I’m part of something...  I’m part of a team, and we’re working to make things better.”
*- Information Resource Management*

**Notes:**
The additional value to including everyone who has responsibility for taking care of patients is that it improves their job satisfaction and it acknowledges their role in providing excellent care to our patients.  As an example, one of our information technologists noted that, “I’ve worked here for 2 years and this is the first time I feel like I’m part of something...  I’m part of a team, and we’re working to make things better.”

## Improvement is not easy DM Comprehensive Care

**Notes:**
Improvement is not easy... some don’t succeed, but the other sites help them to continue to try.

## #1 Reason for Pilot Sites Reaching their Goals?

*Leadership!*
*“**Attention is the currency of leadership”* 						- Ronald A. Heifetz

**Notes:**
The next lesson from this year is Leadership is essential to improvement.  As noted by Ronald A. Heifetz, “the currency of leadership is attention.”  One example of this was told to me this year.  A clerk who was a part of the care team could not come to a planning meeting because she had to cover the front desk.  When the CEO heard this, he went to the front desk and relieved her by covering the desk himself because it was “more important that she be at the meeting.” 
When the midlevel management discovered what had happened, this was the last time that the CEO had to cover for her, and it was the last time that anyone doubted how important these meetings were.

## LeadershipDiabetes Comprehensive Measure

**Notes:**
Another example of how important leadership is to improvement is out one site that does not have an information system.  Despite this handicap, this team has been able to make substantial improvements, mostly because of strong leadership.

## Importance of Nurses in Improvement (e.g.’s)

- Leading improvement teams
- Leading huddles in preparation for visits
- Planning for visits
- Patient follow-ups
- Patient self-management
- Group visits

**Notes:**
Another essential piece of learning is the importance of nursing in improvement.  Nurses throughout the pilot sites are taking active roles in leading improvement teams, leading huddles in preparation for visits, planning for visits, patient follow-ups outside of provider visits, improving patient self-management, and leading group visits. 

## Importance of Nurses in Improvement DM Comprehensive Care

- Nursing Order Entry of optometry consults when due

**Notes:**
Although it is a low level example, nurses at one site single handedly improved retinopathy screens by ordering the optometry consult when it was due. 

## Average visit cycle timePatient experience

**Notes:**
Our improvement in the health care can’t be achieved without improving our patient’s experience of care.  As such one of the measures that we are addressing in the collaborative is the cycle time that patients experience when they come into the clinic.  Teams are making substantial improvements in this and it is improving patient satisfaction.

## Care Across ConditionsIntake Bundle (Dep, BMI, BP, IPV, Tob, Alc)

## Model for Improvement

- What are we trying to

- accomplish?

- How will we know that a

- change is an improvement?

- What change can we make that

- will result in improvement?

**Model for Improvement**

**Act**

**Plan**

**Study**

**Do**

**Notes:**
I have outlined the will that teams have to change and also some of the ideas that teams are using to improve the care at pilot sites.  The way that these improvements are achieved is that last piece; the execution of the improvement.

The execution of improvement relies heavily on the Model for Improvement, and the motor of that improvement is the PDSA.  In the Indian Health System, I have been accustomed to the PDSA that lasts a year.  Some of our accountability measures have perpetuated that believe.  The Diabetes Audit is typically referred to as the Annual Audit and GPRA is typically run annually.  Fortunately, these systems have the ability to run data on a more frequent basis. 

## 
“Some is not a number, and soon is not a time...”
- Donald Berwick, IHI’s President and CEO

*“**Some is not a number, and soon is not a time...”*
- - Donald Berwick, IHI’s President and CEO

**Notes:**
The Clinical Information System tools to help us run measures on a much more frequent basis, and PDSA’s should be quick.  Dr. Berwick noted that, “Some is not a number, and soon is not a time...” And, this is the sense of urgency that the pilot sites are using to drive improvements.

## Testing Changes

**DATA and Learning**

- Very small scale test (Small Cost of failure)

- Adaptation and follow-up Tests

- Wide-scale tests of adaptations

- Implementation of adapted guideline(Large cost of failure)

**Notes:**
They no longer plan and do, but instead turn around to find whether their change has resulted in improvements prior to spreading to a larger population and thereby decrease the risk of failure.  This helps to gain a bit of traction prior to trying the change on a larger population.

## IPC-Pilot Sites Geographic Isolation

**Notes:**
One final lesson that we have learned through this year is that we can overcome geographic isolation.  

## Overcoming Isolation Working in a new way

- >30 Webex sessions with all teams on.
- Two virtual (Webex) Learning Sessions
- Last two Open Door Forums with Webex
- CCI Staff
- CCI/IHI Partnership

**Notes:**
We now work in a “new way.”  Through Webex, teleconferencing, listservs, and the use of the internet we can knock down the barriers of distance and lack of transparency.  We have done this with the teams and the CCI and IHI teams function in a true virtual office.

## 
“I was thinking that I might retire until this stuff came along.”
							- B.C, MD 

“I have been in Indian Health for 28 years, and this is the first time that I have real hope that things can be better.”
					- C.S., RN

*“**I was thinking that I might retire until this stuff came along.”*
- 							- B.C, MD
*“**I have been in Indian Health for 28 years, and this is the first time that I have real hope that things can be better.”*
- 					- C.S., RN

- Hope

**Notes:**
This has given us the hope that things can be different.  When improvement is tangible, people like their jobs.  
“I was thinking that I might retire until this stuff came along.”
							- B.C, MD 
“I have been in Indian Health for 28 years, and this is the first time that I have real hope that things can be better.”
							- C.S., RN

## GPRA: 2006

**Cancer Screening: Colorectal**
- AI/AN patients ages 51-80 who have received appropriate Colorectal Cancer Screening

- Patients who received screening

- Patients who did  **NOT** receive screening

**Notes:**
In a system where we only screen for colorectal cancer in 22% of our patients there is much room for improvement. 

## Colorectal Cancer Screening

**Notes:**
And, our teams are showing that this improvement is possible.  
Who here will not get their colorectal cancer screening done?  Let’s not even get into the argument of which is better, colonoscopy or FOBT and whether we can afford the colonoscopy.  It doesn’t really matter... what about the other 80% of the population?

## Care Model

**Informed,**
**Empowered Patient and Family**

- Productive Interactions** **through effective asset based partnering over time

**Prepared,**
**Proactive**
**Practice Team**

**Improved achievement of patient and community goals**

**Delivery****System**
**Design**

**Decision**
**Support **

** ****Clinical****Information****Systems**

**Self-****Management ****Support**

**Health System**

**Resources and Policies**

**Community **

**Health Care Organization**

**Care Model**

**Patient**** ****Driven**** **

**Coordinated**

**Timely and Efficient**

**Evidence-based and Safe**

**Notes:**
We can use the Care Model to come up with the ideas to improve colorectal cancer screening. 

## Synergy“the phenomenon in which two or more discrete influences or agents acting together create an effect greater than that predicted by knowing only the separate effects of the individual agents”

*	****IHS**** Mission...*
- 	to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

**CCI**
** ****IPC/IHS**

** ****IHI**** ***Strategies*

- _Motivate_:  Build will and optimism for change

- _Innovate_:  invent new solutions, create new healthcare models with far superior value

- _Get Results_: partnerships that can leverage results for thousands; learn from and assist leaders to get results.

- _Raise Joy in Work_

- Support community and individual wellness and strength

**Notes:**
We are using our partnership with IHI to learn how to improve.

## Where do we go from here?   (Spread)

**IPC I**

**IPC II**

**Capacity Building**

**Readiness Curriculum**

**Full Scale**

**Where do we go from here?   (Spread)**

**Second Round of Full Scale**

***Intensive work with initial 14 pilot teams***

***Addition of 25 new sites to the IPC***
***Includes readiness stage, sequencing and staging changes***

***National collaborative for 200+ sites supported by regional infrastructure***

***For sites not ready the first time around***

***Training of initial coaching teams (6 – 12) to support improvement in the field***

***Training remaining sites (200+) on models, project management and leadership for improvement***

**Five**
**Million**
**Lives**
**Campaign**

**Notes:**
We are going to spread the improvements to all of the Indian Health System over the next few years.

## Lessons Learned

- Hope
- Improvement is everyone’s business
- Waste
- Improvement work can increase staff and patient satisfaction
- “Dietitian” is spelled with **two** t’s

**Notes:**
The lessons that I have learned this year have made all of the difference.  They have given me hope... real hope that things can be better.

I have learned that Improvement is everyone’s business... it has to be... all of the way to the janitor.  There was a bathroom that used to be a “staff only” bathroom.  It had to be opened to patients during remodeling.  

Unfortunately, the staff began to complain that they wanted it changed back to “staff only” when it became unbearable and “too dirty to use.”  

Whoa... What?  What do you mean, you want to make it a “staff only” bathroom?
What is wrong with this thinking?
What about, “Let’s clean the bathroom more often?”

This is equity!  If the bathroom is clean enough for patients it should be clean enough for staff. 

I have learned that there is a ton of waste in the system and we have to get rid of it in all forms.

I have learned that there are two t’s in dietitian... just an FYI if you are going to give a presentation to the dietitians... make sure that you spell your title slide correctly.

## Lessons

- Continuity (*Relationships*) are essential
- With the patient
- Within the care team
- I want to work in an Indian Health System where I don’t have to ask for favors to get the best possible care for my daughter.

**Notes:**
I have learned that relationships are the key to improvement.  Relationships between the patient and the care team and relationships between the members of the care team.  

I have learned that “when the enemy is in camp you give the guns to the cooks.”  When people are dying of colon cancer because we can’t get their screening done... when people are dying of breast cancer because we can’t get the mammograms done, we need to include every member of the team who is willing to help.

Ultimately, I have learned that I want to work in a Health System where I don’t have to ask for favors to get the best possible care for my daughter... I want to work in an Indian Health System where I can get the care I want and need when I want and need it.

**Notes:**
I wanted to finish with a slide of the sunrise of my elk hunt this year.  I was hopeful that morning as I rose and prepared long before the sun was on its way.  I am hopeful that we will improve the system.

Just so that you know... my elk hunt was successful.

Thank you for your time.