Managing to Optimize Quality: The Case of Southcentral Foundation

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“So you may be reading this and thinking,
‘Yes I do all of those things – there’s nothing to learn here.’
My challenge back to you is, really?”

-Karen Barnett, NHS (England), reflecting on the success factors of Alaska’s Southcentral Foundation

Southcentral Foundation, a tribal health center in Anchorage, Alaska, is recognized as one of the world’s leading models of health care redesign and is a recipient of the 2011 and 2017 Malcolm Baldrige National Quality Award, the only health center in the United States with this record. Their Nuka System of Care is based on a Native Alaskan value framework. “Nuka” is an Alaska Native word that means strong, giant structures and living things. It is also the name given to Southcentral Foundation’s whole health care system, which provides medical, dental, behavioral, traditional and health care support services to more than 65,000 Alaska Native and American Indian people.

In the Nuka System, strong relationships between primary care teams and patients (known as customer-owners) have helped manage chronic diseases, control health care costs, and improve the overall wellness of the people they serve. Recognizing that individuals are ultimately in control of their own lifestyle choices and health care decisions, Nuka focuses on understanding each customer-owner’s unique story, values and influencers in an effort to engage them in their care and support long-term behavior change.

Southcentral Foundation’s management theory can be broadly defined as “tight-loose-tight.”

“Tight” management means that there is considerable structure that is set by leadership that employees must adhere to. “Loose” management means that there is no rigid structure in place and employees have more flexibility to do as they see fit. Their approach to management employs both types.

There are two major things that are “tight” under this management style.

The first is the overall philosophy and the broad picture of how they approach health care. All care teams must follow the organizational philosophy and operational principles. They must practice relationship-based care and strive to understand the story of each customer-owner they serve. They must make use of communication techniques such as advocacy and inquiry to facilitate the formation of the strong relationships, which are at the core of the Nuka System of Care.

The other element of clinical care that is “tightly” managed is outcomes. Each care team has certain health outcomes, for the panel they care for, that they are responsible for reaching. These health outcomes are tracked and are compared to national benchmarks; care teams are able to view their panel’s status on these outcomes at any time. The team is accountable for reaching these outcomes and if they fail to do so, management will step in and determine how best to support them so they can.

Management of all other aspects of clinical care at Southcentral Foundation is “loose.” This means that the specifics of how the team operates, and how they organize their work day-to-day, is mostly up to the team itself. So long as they are following the philosophy of the Nuka System of Care, and achieving the outcomes they are accountable for, teams have considerable freedom in how they operate. They are free to innovate and experiment. Their management does track what teams are doing in these areas, but only so that practices that are working well can be spread further across the organization.

This “tight-loose-tight” philosophy of management has allowed their care teams a great degree of flexibility while maintaining the values of the Nuka System of Care, and supporting good health outcomes for customer-owners.

Southcentral Foundation shares its best practices on leadership, management, quality, and COVID-19 on its website, in publications and at conferences.

Staying Connected, Virtually

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“I define connection as the energy that exists between people when they feel seen, heard, and valued; when they can give and receive without judgment; and when they derive sustenance and strength from the relationship.”
–Brene Brown

The physical separation forced on us by COVID-19 has led us to better value the connections we have with each other. Video connections can help (compared to email and phone calls) but nothing beats the in-person sighting of a friend or family member, even while wearing a mask.

Not shaking hands or hugging can take a toll, though. Human touch between friends is associated with release of oxytocin, the hormone that stirs maternal and paternal bonding to children. In a sign of the times, blankets containing weighted glass beads that mimic the effect of a hug have seen increases in sales during the pandemic.

Seeing warm friendly smiles from co-workers and strangers is also a rare event.  Seeing a smile triggers the brain’s mirror neuron system, the physiologic foundation for empathy, a key component of successful clinical and professional interactions as well as a promoter of positive feelings.

For health care professionals, the increased use of virtual patient visits, and virtual meetings with colleagues, can impact our professional satisfaction and identity. There are many ways to mitigate this:

  1. Use video instead of telephone for interactions where possible
  2. Ensure video setups allow consistently good quality video and audio
  3. Adjust content to allow more back and forth communication
  4. Use expressive eye contact when interacting while wearing a mask or on a video call