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Building a Company on Culture

At Iora Health, we wake up every day with one purpose—to restore humanity to health care. Through our ever-evolving model of delivering health care, we are able to build meaningful relationships with our patients that allow us to support them on their journey toward health. Every day, in practices across the country, our teams of providers, Health Coaches, nurses, behavioral health specialists and administrative support come together to solve the unique, complex medical and social concerns of our populations in ways we never thought possible. Whether we are caring for casino workers in Las Vegas, Carpenters in Boston or seniors in Seattle, anyone who walks into an Iora practice will experience the same something remarkable—true relationship-based primary care. How is this possible? Culture.

Many of us have come from ‘typical’ health care. We left a culture that we knew could not become what it needed to to care for modern patients. We had to select the best that modern health care culture has to offer—a deep sense of responsibility toward patients, incredible technical competence and knowledge, a tremendous work ethic but leave the rest behind. We created a culture around a core set of values not often found in health care: to feel Empathy, to bring Creativity, to act with Passion, to demonstrate Courage, and to serve with Humility. And then we found people that already embody these values, regardless of their background, and brought them together to form amazing teams.

We define culture as a common set of values that allows every member of the team—clinical, operational, technical, to know how to approach any problem regardless of its novelty. Rather than operating our business from a set of top down policies and procedures, drilled into our teams to create uniformity, we have focused on creating a culture first. Our core values inform every aspect of our work. Embedded in every act, whether it’s how we greet you at our practices, how we build our software, how we treat diabetes, or how we raise funds for the business, is the Iora culture. From this culture spring our strategies, policies and process that make it easier to do what we do best—help our patients solve their problems.

Building a culture-based series of radical primary care practices is not easy — and not for the faint of heart. We are used to falling back on the rules of big health care which are comfortable, but false. However, we know where the old way will get us—to the old place. No perfectly crafted set of rules, no brilliantly designed provider incentives, no amount of quality committee oversight will get us to where we need to be.

Imagine you are the primary care provider on call for your practice. It is 1am and your well-known patient with advanced lung cancer on chemotherapy is calling with fevers. What do you do? Typically, you would gruffly mumble “go to the ER,” if you even received the call. Not at Iora. First, you calm the patient and his wife. You then tell them to sit tight and you will call them back. You call the oncologist (thankfully it is 10pm local time) that you have selected for that patient because of the amazing service that oncologist provides, consistent with our values, to see if this can be managed with antibiotics and an office visit in the morning. When you decide together that it cannot, you call the ER nearest the patient, speak with an attending to prepare them for the patient’s arrival, send what records you can through the antiquated fax system plaguing modern medicine. You call the patient back, (who is shocked to actually get a call back) and let them know the ER is waiting. You also let them know that their Health Coach will call and check up on them in the morning. And at 8:15am they receive a call from their Health Coach who is able to find out exactly what is happening and work with you to plan the next move. Why do you do all of this? Because you love your patients, your work and don’t really need sleep? On the best of days. Because you are paid for every middle of the night well-facilitated ER visit? Hardly. You do it because that is what you do, why you signed up, and because your team would tolerate nothing less from you but excellence. That is the power of culture.

Culture means that even when the way forward is unclear, you can count on each other to build the map to get where you need to go. It means that whether you build software, market Iora Health, or decide where to open new practices, that you work off of the same standards, the same criteria, and seek to optimize the same things. When we think of it, we couldn’t imagine how to build a company on anything but culture.

David Judge

Patients Driving Innovation in Primary Care

In the spring of 2005, a group of innovators came together at Massachusetts General Hospital (MGH). We agreed that the primary care system was failing and wanted to design a care model that would better support both providers and patients. We heard the Institute of Medicine’s charge to make our care model “patient-centered” but weren’t sure about how best to hear and understand the patients viewpoint.

Around this time I met Dr. Paul Uhlig, a cardiac surgeon who had done his surgical training at MGH. He learned of our work and wanted to hear more. I knew that Paul was interested in redesigning care processes but what I didn’t know was that one lunch with him would forever change my understanding of the patient’s role in the delivery of healthcare.

Paul explained that he had been working at a hospital in New Hampshire a few years prior to our meeting when he and other members of his team began an experiment in the post – surgical ICU. He asked the SICU team that was rounding on post-operative patients to join him at the bedside and to engage the patients and their family members in the decision-making discussion that sets the care plan for each day. Typically, doctors would discuss a patient’s case without including the patient or family. Paul believed that deeper involvement of patients and families could build more trust and assist the hospital in tackling some concerns around quality and safety. While some of his fellow surgeons and staff members were very resistant to this idea, pulled them along with him and what he observed was remarkable.

Patients and their families readily asked probing questions and brought insight to rounds that positively influenced the plans. Patients now had a say in decisions which impacted the pace of their recovery such as when to remove lines and tubes, mobilize them out of bed and begin physical therapy. The simple act of inclusion seemed to bring an energy and accelerated pace to their recovery. Paul also observed a positive shift in the medical team’s spirit and morale. Beyond that, he tracked data that indicated steady improvements in quality and safety including patients leaving the ICU quicker than before and with reduced rates of line infections or readmissions for surgery-related complications. As Paul spoke, I knew that what he was sharing would be transformative for me. I was beginning to understand where our primary care system needed to go and what “patient-centeredness” really means.

Perhaps as remarkable as the sustained success of this experiment over a few years, was the twist on this story that he then shared. Despite the rewards that his patients and immediate team experienced and the measurable improvement in the care, Paul’s department and his entire organization remained quite uncomfortable with this approach. Eventually Paul was dismissed from his position and fired from the hospital staff.

Many of us who have tried to redesign health care have experienced similar barriers to innovation due to our physician-centric view of the world. My own journey at MGH was heavily influenced by Paul’s story and other similarly remarkable examples of patient involvement and patient-driven care around the world. Our own group of innovators eventually designed and opened a primary care practice based largely on the idea that patients are the most important member of their care team and when empowered by a supportive culture that embraces them, they will indeed increase their engagement and this can lead to much better outcomes — better than we have ever achieved in the traditional care model.

We have a path forward away from our broken and failing care system. This pathway will be defined most successfully by organizations that understand that when we welcome patients to manage their own health, much of what we have assumed about delivery of care must be questioned and redesigned entirely, especially our culture. Iora Health has created the culture that provides this opportunity for patients and I believe this is largely why Iora will lead the way in defining the future of primary care. It is also one of the most important reasons that I feel so fortunate to have joined Iora on this journey.