Lesson from Nuka – the Alaskan healthcare system by @docherty_e

South Central Foundation

In my previous blog I mentioned the visit I had to the south central foundation (SCF) in Alaska. In fact three members of Cohort 4 of the Scottish Patient safety programme fellowship visited the South central Foundation (SCF) in Alaska for a study tour, myself, Dr Victor Chong and Dr Ciaran O’Gorman.

This study tour was part of the fellowship, as an opportunity to visit a healthcare area that has worldwide renown for patient safety and person centred care.  SCF has a unique system of care, called Nuka. “Nuka” is an Alaskan Native name given to strong, giant structures and living things.

This Nuka system is a relationship and culturally based primary health care system that has an international reputation for excellence in care, with a number of highly impressive outcomes since its inception in 1982:-

• 50% reduction in emergency room and urgent care visits
• 65% decrease in specialty care requirements
• 53% reduction in hospital admissions

As a nurse clinician within a secondary care environment I was keen to view  a system that could generate these figures, as many of the day to day pressures I am under feel linked to high volume admissions profiles.

Part of the education of an SPSP fellow includes exposure to some of  the underpinning paradigms that facilitate high quality health care. One of the fundamental social “equations” we look at is:-

                 Structure + Process + Culture = Outcome

I had seen the exceptional outcomes, I wanted to experience first hand the fundamental aspects of the rest of the equation.

We quickly established that many of the aspects of structure and process, whilst incredibly effective, seemed to generate from the culture of the organisation. This working culture was one of the most inspiring aspects of health care I have ever experienced.  An evolved system that truly encapsulated person-centred care, I found an ethos that permeated the system through every person, whether clinician, manager or ancillary staff.

Culture

The Nuka system is based on 4 principles

1. Customers drive everything

2. Customers must know and trust their health care team

3. Customers should face no barriers in seeking care

4. Employees and supporting facilities are key to everything.

All individuals I met, from the medical director to receptionists, seemed to completely embrace these principles, indeed these values. They have no patients. They have customer owners and seem to have a clinical culture based on a servant leadership paradigm.

This idea of customer owners is central to Nuka. Post legislation, all care for the indigenous populous is free at the point of care, with the Federal government paying a large portion of costs. This legislation is based on a “pay-back” for previous legislative issues. Given this, the patients do own the system. And the system feeds back that to own the system they have to take large levels of personal responsibilities for the system. This level of personal responsibility is also then taken to the aspect of personal health. All health care professional were very clear on this. The customer owner not only owns the system, but their own health. Professional intervention is always seen as supportive and person centred. Quality ambitions that echoed immediately with all the visitors

Structure and Process

At the heart of this are small, integrated primary care teams not only deliver care to customers but also seek to know them and develop relationships with them. This multifaceted team includes a physician; case manager; dietician; behavioural therapist and a variety of other health care professionals.

One of the unique functions of these teams is the ability of the customer owners to access all members of the team. Whilst this sounds simple, most systems focus on primary care physician led models, with all patients being reviewed and referred on by medical staff. In this system all the team members can be directly accessed, with team members being encouraged to “work to the top of their licence” i.e. doing the work only they can do. This actually significantly frees up medical time, allowing same day access to the physician

Primary care teams remove barriers by same day appointments as the standard and all team members are accessible by phone and email with a drive towards specialty care having the same access.

What I’ve taken away?

I’ve been very used to working on 1 year and 5 year plans, SCF spoke of generational plans.

– Eliminating child abuse within a generation.

– Re-establishing the system of tribal elders within a generation. 

– Planning for health over the next 100 years.

– Changing a whole healthcare system within 30yrs.

SCF have a remarkable clinical and corporate culture that puts each patient, each family, and whole generations of Alaskan native people at its heart. As my leadership role with my health board begins to encompass whole island populations, I have “stolen with pride” some of the cultural drivers that make SCF a world leader, and try to integrate them at a, clearly, much smaller scale, into the planning of systems and processes for this new development.