Reconnecting McDowell takes a boundary-spanning approach to solving the complex issues of McDowell County, WV. Rather than trying to fix education from within the four walls of the classroom, Reconnecting McDowell knows it takes individuals and organizations working across boundaries to create a healthier community. Reconnecting McDowell’s partners – public and private businesses, foundations and academic institutions – are working together to revive the area. New programs will bring books to children who can’t afford them, provide better access to health care, and make large infrastructure changes, such as providing broadband internet access, making road improvements and building housing for teachers. Reconnecting McDowell is proof that health is more than health care.
In June 2012, a PHAB team traveled to Alaska to visit the Southcentral Foundation, a truly boundary-spanning organization.
Southcentral Foundation's vision is a Native Community that enjoys physical, mental, emotional and spiritual wellness; its mission is to work together with the Native Community to achieve wellness through health and related services. Its customers own, manage, direct, and design the Southcentral Foundation's Nuka System of Care. This is an approach that those within the foundation believe can be translated into other clinical settings.
Here is what our PHAB associates found.
Southcentral Foundation, Report by Rochele Beachy, MD & Nathan Beachy, MD
Nuka System of Health Care
South Central Foundation
Winner of 2011 Malcolm Baldrige Presidential Award for Quality in Health Care
South Central Foundation is an Alaska Native-owned nonprofit health care organization and serves the Native Alaskan Community. In 1999, South Central Foundation signed an agreement to take over ownership and management of Alaskan Native medical care in their region from the Indian Health Service. Since then Leadership, over the years, has developed a patient centered, team based model that meets the patients’ needs while all employees of the system also thrive and enjoy their jobs. Their patients are called ‘customer-owners, not patients’, because each have ownership in their health care system. It is believed that changing the dynamic from considering people ‘patients’ to considering them ‘customers’, changes the way the person is perceived and treated. A customer needs to be given a service they desire and needs to be satisfied, a patient can be looked upon as someone who needs a service and thus is at the system’s mercy. Leadership actually looked initially at Disney as a model for how to deliver customer friendly care.
One of the key elements that make South Central so different is that they invest in employee training up front. They believe that first encounters make lasting impressions so they put good people on the front lines and train them extensively. Each front desk staff, which we would call a PSR, goes through a 6 week training program in their Development Center, before being assigned a position. About 1/3rd of these trainees do not make it through the training to completion, thus are ‘weeded out’. They are paid during this time at a ‘trainee’ salary and there is no commitment to continue on the part of the organization until training is completed. At the end of their training, there is a ‘speed dating’ type process where those in need for front desk staff interview those ready for an assignment and trainers have input into where trainees would fit best. For example, someone who works quickly and efficiently might be assigned to a high volume team; someone who is more deliberate with a high attention to detail would be assigned to a team with very sick patients. Once they are assigned, they have an ‘administrative mentor’ who sits beside them and does the same job and is responsible to continue their training and supervision. Being a mentor is an upgrade/promotion and comes with a pay increase. In addition to the mentor, the office supervisor sits directly behind all front staff to supervise and advise on a minute to minute basis.
Similar training is provided for everyone specific to their job. South Central Foundation believes strongly in the advancement of their employees and gives opportunities, like becoming a mentor, to everyone in every position. Moving around the system to better job opportunities is encouraged. Every employee has a Personal Development Plan.
Employees are trained in anticipation of hospital/clinic needs based on turnover rate, so trainees are ‘ready to go’ when positions open up. Contrast this with someone quitting and the clinic having to go short-handed for 6 weeks while someone is hired (but not trained).
Having supervisors directly behind the front desk staff is an example of how South Central has ‘de-officed’ everyone. Even vice presidents share offices so there is ongoing input and constant opportunity for conversation about decisions being made. No one on the teams is in an enclosed office.
The primary care team consists of:
- Provider (either a doctor or a mid-level provider who has advanced to this level),This person is the team leader
- Nurse, who is the care coordinator
- MTA, who runs the floor
- Administrative care coordinator—this is a ‘step-up’ or opportunity for promotion from front desk staff. Customer owners who are assigned to the team are given a direct number to this person for scheduling and contact for all issues.
In addition to these essential team members, each 3 teams have a behaviorist and a nutritionist. These providers sit with the 3 teams and are available for ‘right now’ consultations and visits with customer owners. These providers facilitate getting the PCP out of the exam room, as they can take over care (and do so better) when behavioral issues or dietary issues come up. They are expected to see customer owners regularly in times of change in a family system, such as during childbirth and the first 5 years of life.
Each team has their desks together to facilitate face to face contact and 3 teams occupy one large linear room space, so they can see where the behaviorist and ancillary personnel are.
Behaviorists are master’s level social workers or psychologists with counseling training. Training is also done on site for the jobs they do specific to the team. Again, hiring the right people is emphasized. They look for people who can jump from room to room and don’t require an office and long visits to do their job well. The hiring of Behaviorists was initially resisted by Family Medicine providers, but after a 6-month trial, most providers stated that the behaviorist was their most valued team member.
In South Central’s concept of the medical home, continuity is the first priority, such that they do not have teams covering for each other. They strongly encourage each customer owner to only have a relationship with one team. Thus, they have floating mid-level providers who cover a team if a provider is out; patients aren’t seen by other teams, ever. Since other members of the team know the patient well, there is minimal drop off in the quality of care.
They also have same day access, and same day, real time phone service, so the need for urgent ‘just in case you get worse’ type appointments decreases significantly. Patients can call back and get back in immediately if they get worse. Each physician does one evening clinic a week and a Saturday on a rotating basis. Providers see an average of 8-10 patients per 4 hour session and have administrative time scheduled. In addition, there is no call or phone number for patients to call after hours. Since patients can get in the next day, they often wait. If they have a true emergency condition they go to the ED. There is no telephone triage. One would think that this would lead to increased ED visits but the opposite has happened because of the high level of trust between customer owners and their team and immediate access during office hours.
Another wonderful and unique feature of their team based care, which greatly decreases physician burnout, is that everyone works at their top level of training. They have taken the physician out of many clinic interactions and admit they have been set back in this process by electronic medical records, which are designed to make EVERYTHING flow through the doctor. They are working to modify their EHR which went live two years ago, so that work flow matches what they had previously achieved. The doctor should not be the ‘rate limiting step’ and does not need to see everything that is done all the time. Simple orders are routed through administrative staff; refills and referrals are routed through care coordinators, etc., so the doctor’s in-basket work is appropriate and never secretarial.
Team panels vary from 1200-1700 customer-owners depending on medical complexity. There is no physician incentive plan, since seeing patients is not necessarily the best way to manage all issues. Phone contact and secure electronic contact is encouraged, so that patient needs are met based on what they need, not how often they are seen. The question they are addressing is “Are we advancing the health of the community?” in contrast to “Are we meeting our numbers?” Approximately 30% of patient encounters are currently virtual. They foresee up to 70% of care being delivered outside of the office in the future.
Perhaps the most important thing South Central Foundation does is a 3 day training for each employee called Core Concepts. This training is based on work done by Peter Senge (The Fifth Discipline), who helped them modify their training. The key is that all staff are in relationship with each other, understand their own work/relationship styles, and most of all hear each other’s stories. Top level administrators including the CEO share their stories, which are personal and sometimes painful, at ALL training sessions.
One concept that was stressed is that 100% of primary care is based on ‘messy human relationships’. To deliver excellent primary care, not only do teams need to be in relationship with customer-owners,they need to be in relationship with each other. Lean Six Sigma works well for the 35% of medical care that is procedure based, like intensive care units, ED visits, and surgical work but does not work especially well for relationship based care. Virginia Mason is a leader in Lean Six Sigma delivery but this delivery system has its limitations and should be utilized in areas of care it is most appropriate for.
Quality improvement and Quality Assurance are separate at South Central Foundation and have separate staff. Busy employees are not expected to do these projects ‘in their spare time’. It is felt that quality assurance is done best by those who are meticulous and quality improvement is done best by those who are imaginative. There are 12 full time improvement advisors/ improvement specialists. Small, quick pilots are emphasized and may be tried for only a day or a week and if it doesn’t work, one moves on to another trial. There are no long lag times for systems/trials that are not working. Anyone at any level can initiate an idea that might be considered for a small pilot. Teams can initiate their own pilots within the scope of their practice. These do not need the approval of a vice president or CEO. If it fits with the mission and strategic initiatives of the organization, it can be started immediately. If it works, there is a system for implementing that pilot on other teams. In addition all strategic initiatives of the organization are available on the intranet to all the employees. The process is completely transparent so all can learn from each other and advance the goals of the organization.
South Central Foundation has focused on the top 5% high patient utilizers who generate a high percentage of total health care costs.
Every customer-owner who:
- Has 2 or more providers
- Is on a pain contract
- Is on suboxone program
- Has had 2 or more non-OB hospitalizations, or 3 or more ER visits in last 6 months, or 12 or more office visits in the last year
gets a Wellness Care Plan. Once the plan is implemented, outcomes include:
- 1/3rd drop in ER visits
- Less duplication of services
- Increased patient satisfaction. A common response is that they feel heard, even narcotic seekers do better. This is a current quality improvement project.
South Central Foundation has concentrated efforts on change in families during a child’s first 5 years of life. This is based on data from Kaiser’s Adverse Childhood Experience Study. Alaska ranks high for domestic violence, child abuse and child neglect. Families are most likely to change around a pregnancy. Childhood trauma affects all areas of health, including predilection for chronic diseases like heart disease. The number of childhood traumas one is exposed to increases one’s risk exponentially, and so reducing childhood exposure to trauma has become a focus of South Central Foundation. The return on dollars spent in the first five years of life in terms of disease prevention is high. This starts with Wellness classes for moms that start with a positive pregnancy test. They have classes for young pregnant women, young parents with infants, and young parents with toddlers. Behaviorists see women throughout their pregnancy and at well child care visits, a time when family systems are most likely to change. This project is called New Generations.
In addition, South Central has a Wellness Warriors Initiative, for those who have been abused and who have abused, an intense 5 day overnight program to “End domestic violence, child abuse and child neglect in one generation”.
An innovative program to encourage constituents to pursue health care careers is called “RAISE”. This is an internship program in which 14-18 year olds get hospital/clinic experience. Over the years many RAISE interns have become employees of South Central Foundation.
Facility design is something else South Central has focused on, as well as care of their employees and customer owners in a holistic way that includes a Wellness Center with many classes and exercise opportunities.
Outcomes of South Central Foundation are impressive.
- They are in the 95th percentile in achieving Hgb A1c goals
- Childhood immunizations are at 93%
- They are in the 75-90th percentiile for HEDIS outcomes and quality.
Cost savings to the system are realized by decreasing need for hospitalizations and emphasis on primary/preventative care. And the health of the community has improved!
It is our belief that this model can be implemented in any health care setting given the right support and leadership buy-in. Leadership would greatly benefit from a visit to South Central Foundation or participation in its Annual Conference.
Southcentral Foundation, Report (Q&A) by Nathan Beachy, MD
Report on the Nuka System of Care Conference in Anchorage, Alaska June 18-23, 2012.
The Southcentral Foundation defines health using the World Health Organization definition that emphasizes well-being or wellness. Their vision statement is, “A native community that enjoys physical, mental, spiritual, and emotional wellness.” This commitment to more than just the physical aspect of health is manifested by;
- incorporating symbols that are culturally and spiritually significant to native people in the facilities,
- including native healers within the organization in a way that values their contributions to the community,
- using behaviorists in the context of the health care team rather than separating this aspect of care from the rest of the care that is given,
- a wellness center at the facility with Zumba instructors, dieticians etc. It should be noted that while most institutions would recognize the definition of health as given above, the usual path is to separate all those aspects of health as if they do not affect each other. The Nuka system of care encourages these four aspects of wellness to be seen as interrelated and addressed together if possible.
The most important skill is to listen to their customer/owner’s stories and to respond to it in a way that is affirming. One of the things we heard is that the number one determinant of a person’s health and long life is self-confidence. That changes the focus from dispensing of knowledge to empowerment of individuals, family systems and communities. Good listening can be taught, but it happens in a more robust way if it is modeled throughout the organization and the persons within the organization have experienced it in a personal way.
Beyond the shared mission and vision, it is important to articulate the mission and vision in a way so that everyone understands it. An advantage that SCF has is that most of their employees and their families receive their care there, so it is important to everyone that it works well. Another trait that is important is a constant push towards improvement, with a willingness to listen to everyone that has a complaint or a suggestion. If improvement is paramount then divisions between departments become less important. Resources are allocated with this priority in mind and SCF has 12 full-time quality improvement specialists. Transparency regarding specific goals and objectives for the organization and for each department increase trust and are critical to an environment where people can integrate their skills in a way that is effective.
SCF has an expectation that work will intersect and this is encouraged. Their structure has a vice president that is over four functional committees as follows:
- Operations: effective day-to-day operations
- Quality assurance: compliance with standards, etc
- Process improvement: improving systems and structures
- Quality improvement: improving clinical and educational structures
These committees can make improvements that agree with the goals of the organization without obtaining approval first. Everything is measured relentlessly and shared broadly, which is a self correcting feature of their system. The transparency of all goals and initiatives throughout the organization allows employees to plug in to what interests them with some negotiation of course. Everyone is expected to advance, so it is expected that jobs will change.
The CEO Catherine Gottlieb went from administrative assistant to the CEO to become the CEO without a college degree. She has infused the organization with an attitude that everything is possible here. She is constantly asking why can’t we do this better for our people and is willing to be vulnerable to all her employees. The Core concepts that were the first 3 days of the Nuka conference is the same “course” that all the employees go through. During that time she tells her story as do some of the vice presidents, and their willingness to make themselves vulnerable opens up all kinds of possibilities for the employees. Their organization now feels more like a family than a place of work and the organization is rewarded by people who work hard. Despite the “family feel,” there is not an expectation of keeping things within the family. It was on the second day of the conference after the attendees had been introduced to the Nuka system of care and it’s very impressive results that Ms Gottlieb announced Alaska had the highest rates of physical and sexual abuse in the country. We were all singing Alaska’s praises at this point in our experience and I would have expected there to be some basking in the adulation. Instead she was determined to shine a light on this behavior and stated that her goal was to effectively stop this within a generation. Once again her willingness to show vulnerability is boundary breaking in the sense that it opens up the possibilities that this can change rather than turning away from it, because it causes some discomfort.
The Core concepts certainly initiates the boundary spanning culture, and it is reinforced by people being encouraged to tell their stories within their teams, so that people will better understand each other. In addition to the story telling they have done lots of work with Peter Senge’s work The Fifth Discipline which gives employees ways to articulate a relational style.
The primary goal here is to promote health within the population and boundary spanning occurs on the way to that goal. The idea is not to set out to cross or span boundaries, but if it needs to be done to promote health then it will be done.
In this context, I would say it improves health by providing an environment for healing. Especially in regards to personal relationships. If people can talk about their wounds then they can begin to heal.
It needs to be shared widely, and successfully implemented in other settings. In their present setting, the Nuka System of care has been remarkable, and it is hard to think of how it could be improved.
Culture plays a large role in impacting health. The ability of a health system to impact the day-to-day choices people make is minimal. Culture can play a much bigger role. Health systems have traditionally been very good at episodic and emergency care. Continuing with this approach will not change the health of a population. David Hylton, who was a missionary surgeon in Nigeria, who worked 70-80 hours a week in a community there, said that after 10 years of doing several surgeries a day and taking care of up to a hundred inpatients, he noticed that his impact on the health of the community had been zero. He thought that maybe we need to focus on the sense of well-being as noted in the WHO’s definition of health. He ended up working at WHO and stated that he could not find anyone who even knew anyone who was working on improving people’s sense of well-being. Everyone was working on specific diseases. The Nuka system of care actually puts wellness first rather than just paying lip service to it.
In conclusion, SCF has made great strides because of their willingness to cross boundaries within their culture, and discard the predominant “sick care” culture that separates in the following ways:
- Separates the mind from the body and treats these as separate entities not related to one another.
- Separates different organ systems, carving up people into their component parts, and then treating each part separately.
- Separates patients from the context in which they live, so that a health care system’s role is to give advice without being mindful of the culture or the family situation etc. that is part of that person.
- Separates providers from their patients in ways that ultimately prove dysfunctional for both. While providers need to be able to emotionally distance themselves in urgent situations to do what needs to be done, Most of medicine and almost all of outpatient medicine depends on messy human relationships.
- Separates health care workers from each other (especially physicians) in a hierarchical model that handicaps the health care team so that it functions at a lower than optimal capacity.
- Separates within health care institutions in regards to the ability of each department to make money for the institution. This causes some departments that may be very valuable in improving the health of a population to be undervalued in the institution.
The Nuka system of care crosses boundaries in all kinds of ways, more than what is listed above. Part of their success may be attributed to their situation in which they had to create a new health care system almost from scratch and the leadership’s willingness to do things in a different way. Part of their success is due to the leadership making themselves vulnerable enough to really listen to their customer/owners and employees. Part of their success may be due to them being relatively isolated in Alaska without a lot of outside interference. But, most of their success is due to having the courage of their convictions and acting on them despite the boundaries they would have to cross.
Southcentral Foundation, Report (Q&A) by James Lalumandier, DDS, MPH
I attended the General Conference  to learn about Southcentral Foundation’s Nuka System of Care.
As stated around the Core Concepts, “Southcentral Foundation’s Vision of a Native Community that enjoys physical, mental, emotional, and spiritual wellness.” Although not a part of the workshop on Core Concepts, it seems Southcentral Foundation is well indoctrinated into the Core Concepts during their orientation – everyone is on the same page.
Because the organization believes in holistic health care, it allows their staff to be boundary spanners. The Core Concepts can be taught and is obviously well taught for all to be on the same page.
Southcentral definitely has set goals and a very strong philosophy of health care which is holistic in nature.
With strong Core Concepts and a philosophy of holistic health care, Southcentral is a powerful influence on the individual staff member.
Southcentral has a set geographic sphere of influence with a population of predominantly Native Americans who have routinely had very poor health outcomes in nearly all aspects. This overwhelming need in a defined area with the same population leads to a holistic view of health care and boundary spanning.
Southcentral’s Core Concepts and holistic health care is successful in a holistically defined health care outcome. This success story has led to awards, continued funding and courses to teach others their philosophy.
Primarily the boundary spanners focus on prevention.
With Southcentral holistic health care, prevention and care teams are truly patient-centered. Care team mentors continually analyze treatment data to determine the best practices and continually share best practices with other teams. The bottom line is better health outcomes for all patients.
Unfortunately, dental is a stand-alone entity – include dental into the care team concept.
Southcentral Foundation, Report (Q&A) by Charley Willison, former PHAB Fellow
NUKA: Case Study, 2012
Boundary spanning is reaching across borders, margins, or sections to 'build relationships, interconnections and interdependencies'* in order to manage complex problems.
PHAB takes a broad view of health as a state that enables people to do valued life activities.
In the case of Nuka, boundary spanning applies to reaching out to other people in the sense of social networks and social connectedness. Relationships affect every aspect of our lives, specifically our health. By focusing on boundary spanning by forming relationships, healthy ones that support all individuals involved, health may be improved.
Nuka has also applied boundary spanning to organizational or ‘business’ boundaries. Based on the same principle of a general respect for persons through meaningful relationships, Nuka spans boundaries by creating a system-wide (organization-wide) approach to improvement. They have adapted a model of PDSA cycles, with the creation of a culture of continual quality improvement. This model does not apply to small sections of the organization, but to the system as a whole, so no part is left out, or goes without improvement. Working on the system as a whole also creates continuity, improving the overall satisfaction and quality of the organization (principles used are from the Baldrige Foundation.)
Nuka leaves nothing unturned. The boundaries, again, are based on a framework of quality relationships. Thus, the foundational boundaries focus on communication skills, conflict management, story telling (communication), and teamwork.
Working together with the Native Community to achieve wellness through health and related services (Mission).
Core Concepts and Key Points: Shared Responsibility, Commitment to Quality, and Family Wellness.
- Working together in a relationship to learn and grow
- Encouraging understanding
- Listening with an open mind
- Laughing and enjoying humor throughout the day
- Noticing the dignity and value of ourselves and others
- Engaging others with compassion
- Sharing our stories and our hearts
- Striving to honor and respect ourselves and others
Yes, everyone can learn to be a boundary spanner. In a sense, Nuka works to promote every person involved, as a boundary spanner. This includes customer-owners (patients), providers, employees, and board members. An interesting example is the inclusion of both those who have been hurt by domestic violence and those who have done the hurting in domestic violence situations, in a group counseling and wellness session called Family Wellness Warriors Initiative, or Beauty for Ashes specifically.
In Nuka, there is a hierarchy, but it is a very democratic organization with a lot of transparency from the top-down. All employees are involved in the same basic training process of core-concepts, and everyone from the patients to the employees are encouraged to provide feedback, and allowed to in non-intrusive, easy ways that do not require a lot of effort. This feedback is taken seriously and used to improve the system as a whole, crossing boundaries back to the top to initiate change.
Organizations involved must accept the mission and vision of Nuka. Those who disagree with Core Concepts will have a hard time participating. Organizations must be ready and willing to accept continual change and strong and open relationships. These organizations must in turn be willing to accept continual criticism.
This is the foundation of Core Concepts! Working together by working through differences is a very important concept. Challenging ideas is just as important as agreeing with them, both must occur for change and improvement to happen. However, it must be in a professional and responsible manner.
A common goal is necessary. Nuka was able to initiate the initial changes by applying the Malcom Baldridge framework to their organization. This included creating a very high, but attainable goal, and sticking to this goal. Without a set outcome, or with conflicting ideas, it may be hard to progress. Initially, before a goal is chosen, deliberation and disagreement is welcomed.
A common goal, strong communication, and the utilization of PDSA cycles. Boundary spanning needs strong leaders to begin the process, but the most successful result in systematic change.
I feel that Nuka has appropriately identified relationships as the foundational factor that defines our health (besides genetics, which could be considered another type of relationship). All other factors stem from these.
Charley Ellen Willison, B.S., M.P.H., M.A., former PHAB Fellow
Southcentral Foundation, 2012 Report by Mary Ruhe, MPH, RN
- Type of Boundary Spanner Organization: health care system
- Location:Anchorage, Alaska
- Population:Native Peoples of Alaska
- Total system-wide transformation of care
- Customer-owners [community need driven, shared decisions, service model
- Intensive system-wide training in relationship building and mentoring
- Opt-out hierarchy
- Walk the talk every day – water cooler discussions and more.
The Southcentral Foundation (SF)is a comprehensive wellness system created to replace the federal Indian Health system that provided medical care to Native Americans in Alaska. Southcentral began building their system of care in 1997 with a culture that considers ongoing adjustment and progress to be the norm. The patient population or “customer owners” are all, to varying degrees, native people. The population is known to have high rates of alcohol and drug abuse, and family violence and child abuse/neglect. The system mission is to “work with the Native Community to achieve wellness through health and related services.”
Southcentral Foundation serves 60,000 Alaska Native and American Indian people living in and around Anchorage and in 60 rural villages. SCF employs more than 1400 people in over 65 services. The vision of SCF is “a Native Community that enjoys physical, mental, emotional and spiritual wellness.” The customers own, manage, direct and design the “Nuka” system of care by “listening to the wants and wishes of those receiving services; redesigning services around long-term trusting relationships; and, empowering customer owners to own health issues at personal and system levels.”
The most striking aspect of SCF is the evident embrace of the vision and mission of the organization by everyone in the system. These are not statements that reside only on a website and promotional materials, but are known and practiced principles that shape every aspect of organizational life. The CEO recounted that she is often asked the most essential thing to do if an organization wants to emulate SF and her response, she says, is to live your mission on a daily basis. While this may not seem innovative it is certainly rare. When deconstructing the processes involved in this culture change the novelty becomes clear. The changes implemented are interconnected and end up being more significant in their totality than independently.
Total system-wide transformation of care
Southcentral called their new system of care “Nuka” from an Alaska Native work used for strong, giant structures and living things. This choice of terminology frames the entire system transformation. The Nuka system of care was to be comprehensive and tailored specifically to meet all the health needs of the native peoples; physical, mental, emotional and spiritual. The new system was not to be bound by current practices in the healthcare field but on the needs and wants of the “customer owners.”
In addition to creating an inclusive whole person and whole community serving system of care, the people and communities being served were also considered to be owners of the system. Literally a significant amount of funding came through the federal government as a guaranteed service to the native peoples. The previous Indian Health Service (IHS) system was funded much the same way, yet a major part of the impetus for change was the poor health of native peoples and their communities under the IHS. Because the Nuka system recognized the native peoples as owners multiple avenues for their input were built into the design and ongoing functioning of the system. The needs and wants of native peoples are elicited, heard and integrated into every decision, structure and process within the system. Transparent and publicly available records and documentation validate this service model at all levels and areas of the system.
Intensive system-wide training
The Southcentral Foundation recognized that a comprehensive and sustainable cultural change into a customer-owner mindset would require education, or re-education. Large upfront investments in employee training were seen as necessary to jump start such a massive change. Every person from the CEO to housekeeping goes through intensive, long-term, mentored training. There was training around employee roles, but just as important, on skills for building interpersonal relationships. Learning how to interact and work with others was seen as essential to develop a new culture of trust and cooperation throughout the organization. The value of educating and convincing employees to not just acquiesce to the organizational mission and vision but to come to believe in it and embrace it led to this same level of upfront investment in every subsequent employee. Every employee knows and believes in the necessity of having a customer-owner frame of reference in order to successfully meet the needs of the native peoples. If this buy-in does not occur, the system or the potential employees decide to separate.
One structure built into the Nuka system of care is the ability to generate and implement changes throughout the system without formal up-the-chain-of-command consent. The decision making structures of the system allow for ground-level experimentation and creativity whenever an idea is determined to fit soundly within the guiding principles of the Nuka system of care. Validation of a change proposal may occur at several predefined functional levels of administration. This streamlining of innovation activity is but one example of how the system is designed to empower all employees to engage in ongoing improvement to best meet the needs of customer-owners.