CONVERSATIONS: PART TWO

PROVIDENCE – While the three day strike [and one day lockout] involving some 2,400 workers represented by United Nurses and Allied Professionals at Rhode Island Hospital and Hasbro Children’s Hospital has concluded, for the moment, the underlying problems confronting the troubled health care delivery system in Rhode Island continue to boil and roil beneath the surface, much like an undersea volcano about to erupt.

The labor strife between nurses and management is not going to fade away; it has become endemic to many regional health systems in New England faced with choices of how to manage dwindling resources and escalating medical costs. When push comes to shove, many hospitals have chosen to put the squeeze on nursing labor costs rather than cut salaries of doctors or administrators.

[In Massachusetts, there is a question on the ballot this November requiring hospitals to set levels of nursing support; if it passes, it will become part of the recent contract provision negotiated with Berkshire Medical Center in Pittsfield.]

The fact is that nurses, not doctors, are the ones most responsible for running the day-to-day operations for most health care systems in both inpatient and outpatient settings, but they are often not compensated fully for the value they deliver in managing patient care, particularly in the shared savings generated by their work in population health management.

And, as documented last week by ConvergenceRI in the story, “The coming health care revolt,” the safety net for the safety net is eroding and corroding in Rhode Island, as Clinical Esperanza, a community health care clinic serving the underserved and uninsured in Olneyville, is considering closing its doors or cutting back on services because of a lack of funding. [See link to story below.]

More than a third of Olneyville residents meet their primary care needs by going to the emergency room, according to a recent survey, and that number is likely to increase if Clinica Esperanza closes. The uninsured rate for Rhode Islanders continues to creep up, according to Marie Ghazal, CEO of the Rhode Island Free Clinic.

Who will make the decisions?
There are numerous, serious, significant ongoing conversations occurring about the future of health care in Rhode Island and the region, but those dialogues are often hidden in plain sight, not accessible to the general public, not part of the daily reporting and coverage by the news media, and not yet connected to any public awareness or political consciousness – except perhaps in the daily struggles by patients seeking to overcome the persistent barriers and inequities in access to health care as medical costs escalate.

Two parallel conversations now appear to be in play at the same time: one by elite members of the health care delivery system establishment at Harvard about how to revamp leadership decision-making; and a second, led by nurses and the Robert Wood Johnson Foundation, about how to build a culture of health focused on placed-based investments.

It is not clear when, if and where these two conversations may intersect or collide; it is also unclear how patients fit into the dialogue, so that their voices can be heard – and listened to – about what they say they need and want.

But, both conversations have important, long-term implications for the future of health care delivery in Rhode Island.

• On Monday, July 23, the first day of the strike, Primary Care Progress, a nonprofit created in 2010 by Harvard Medical School, hosted a talk in Cambridge, Mass., by Chris Fussell, a former Navy SEAL, about lessons in leadership and teaming in changing the hierarchical approach to management and leadership in health care.

Primary Care Progress described itself on its website as an organization that began as an alliance of medical school-based teams promoting primary care and has morphed into a national learning collaborative of current and future health care professionals, from across disciplines and career stages.

In his talk, Fussell addressed what he called human capital, the bond between each team member. The concept was expressed in a tweet from the talk as follows: “What makes high performing teams on the ground successful? These [four] drivers can be directly applied to health care and, when done thoughtfully, scaled across organizations: trust, common purpose, shared consciousness, [and] empowered execution.”

As Elizabeth Métraux, communications director for Primary Care Progress, described Fussell’s presentation: “It was looking at primary care and how we can create more effective, interdisciplinary teams to [achieve] better health outcomes far more quickly than we’ve done in the past,” looking to integrate care and information more efficiently.

“Chris Fussell is not a health care professional; he is a leadership guy, a Navy SEAL, with 20 years in the military, creating high performing organizations,” she said. Most health care professionals have gone through training in a more hierarchical model, Métraux continued. “If we are going to create a culture of health, engage with people with the best minds, the best thinking, and change the way we think about accountable patient care, we need to develop [a new approach],” because the current system is not working.

Another big concern, Métraux told ConvergenceRI, is the high level of burnout by health care professionals and the recent data that physicians have the highest rate of suicides of any industry in the nation.

Translated, the folks that run one of the largest academic health care delivery systems have recognized that they have a big problem when it comes to delivering effective, integrated primary care services, and a potential solution to solve the problems may be through adopting a military team approach.

• On Wednesday afternoon, July 25, at Miriam Hospital, the third day of the strike, the R.I. Action Coalition for the Future of Nursing sponsored a talk by Susan B. Hassmiller, senior advisor for Nursing at the Robert Wood Johnson Foundation, discussing efforts to “Build a Culture of Health” as part of a national nursing campaign for action.

As described on the Robert Wood Johnson Foundation website, the effort toward building a culture of health in the U.S. is under girded by the reality: “Our health is greatly influenced by complex factors such as where we live, the strength of our families and communities. But despite knowing this, positive change is not occurring at a promising pace.”

To accelerate progress, the description on the website continued, the Robert Wood Johnson Foundation has committed itself to a vision of working alongside others to build a national “culture of health,” where everyone has the opportunity to live a healthier life.

Here in Rhode Island, the challenge to create a culture of health is a task that the newly re-energized R.I. Action Coalition for the Future of Nursing has decided to undertake, with the goal of building a coalition of health-related sectors. The current board of directors includes: Maria Ducharme, chair, the chief nursing office at Miriam Hospital; Angela Patterson from CVS MinuteClinic, and Lynn Blanchette, Associate Dean, assistant professor of Nursing at Rhode Island College. Michael Beauregard is serving as executive director.

Following the talk by Hassmiller at Miriam Hospital, ConvergenceRI had an opportunity to sit down and talk with Blanchette, who had attended both the presentations by Fusell and Hassmiller.

Blanchette, who is also one of the founders of the Scituate Health Alliance, the first neighborhood health station in Rhode Island in a rural setting, was willing to share her insights about what she had heard, with the caveat that the story was not about her.

ConvergenceRI: Did you have a chance to interact with Fussell following his talk?
BLANCHETTE: I positioned myself in the room so that I was four rows up from where he was speaking. When he finished his presentation and opened it up to audience, many of the physicians from Partners primary care said: This is exactly what we need to do, to rethink our organizational structure.

I raised my hand and said: I want to pick up on a key element in your presentation, and that is: who are the decision makers? And, who are they empowering to act as leaders.

Because in the military, that [concept] might work very well, you can empower any person in the military to act in whatever way you tell them to.

In the real world, in the health care system, I have a license to practice as a registered nurse; you can’t change what I do.

Just because you think I’m capable of doing it, or you would like me to be capable of doing some of these things, my license says what I can do.

When you change a system to the point where people who have been practicing in a particular model are either outpaced by change or don’t agree with the change, [the choices] are that they can adopt, adapt or leave.

And, in the military, there are people behind that person to replace the one who [decided to leave].

In the health care system, that doesn’t exist.

You have just let an incredibly valuable asset walk away from your organization without considering how else they might contribute.

A nurse, with 20, 25 or 30 years of experience, understands how to deliver patient care, how to develop a relationship, how to work as part of a team, and how to be a member of your organization.

And, because you want to slide them into a new model and they are not willing to adapt to that, you let them go. A model that they had no input in creating, a model that takes what we have and adds to it rather than dismantling what we have and starting over. That model makes absolutely no sense to me.

What tools did you give them to help them make that adaptation? What education and training are you willing to provide them so that they can understand the model?

How willing are you to let them become part of the decision-making process?

Fussell responded: “Those were really good questions,” which was followed by dead silence.

I know that if you change things and lose human assets, people with great levels of skill, because someone who isn’t in the arena makes a decision about how changes should happen, I don’t understand how anyone could think that this was is a good idea.

ConvergenceRI: What happened next?
BLANCHETTE: A nurse who works at the Fenway [community health clinic] was also there, and she raised her hand and said: I have to agree. When you don’t bring these people [into the process] when you’re making the decision, and just tell them how the decision is going to change their practice, I don’t understand how you think that would work in health care.

ConvergenceRI: What is your biggest worry about what you heard?
BLANCHETTE: Who will take authority, or be given the authority, to make decisions. Why does anyone expect a different outcome, a different way of looking at things, when you’ve given the same people the same set of opportunities to do the same thing all over again.

They are not going to make a decision that would disenfranchise themselves or others with the same degrees as they have, and the people who have the same gender. There’s that; we should talk about it, instead of not talking about it.

ConvergenceRI: What did Susan Hassmiller talk about today?
BLANCHETTE: Hassmiller affirmed a lot of what we are thinking about and talking about in nursing: we need to make sure that we’re sharing our language around nurses’ role in the culture of health.

ConvergenceRI: How would you define the culture of health?
BLANCHETTE: Robert Wood Johnson has a definition of the culture of health, and that is health should be a part of discussion in everything we do.

It needs to be part of the housing discussion, it’s part of the economic discussion, it’s part of the education discussion.

When we talk about the need for all-day kindergarten we need to talk about the implications it has for future health outcomes.

It is not just because we will make smarter kids, or provide daycare so parents can work, it’s because we know that kids who get good, early quality education live healthier, longer lives, with their lives being free of disease burdens for a much longer period of time.

In all our policy decisions, we need to be focused on: how is that going to impact people’s health? Sir Michael Marmot has been saying that for decades in the United Kingdom.

ConvergenceRI: Where does the concept of place-based care fit into the conversation?
BLANCHETTE: After the Fussell talk, I spoke with the nurse from Fenway a bit about place-based care. And she said: What’s that? What do you mean?

And I said: You run your primary care clinic, and there is a pretty specific population of patients that come into the Fenway clinic. But you pay no attention to where those people come from, how close they are to you as a service provider. You don’t really know what is going on in the neighborhood right outside your door that may be impacting people’s health.

Where you live matters for your overall health; but you may not think about that at your clinic, or pay attention.

Even if you think about the social determinants of health, and you find out things about what housing is like and transportation, and all those other things, you don’t have any way to impact that except on a person-by-person basis.

I do not think we will ever be successful until we start to think about people living in communities, and leverage our resources around caring for the community to support people, not individual houses, not individual schools, or whatever folks come up with to solve these short-term problems.

We have to change the way we think about when we are open, what services are available, and where those services are located.

ConvergenceRI: And, where we belong?
BLANCHETTE: Yes. But, for me, it’s about when you have a building, your patient population are people who choose to come into your building. That is how it is defined; that is a very different concept then defining it as: we are where the people are.