Cherokee Indian Hospital: Becoming the Provider of Choice Through Trust, Cultural Humility
and Continuous Quality Improvement
By
Leslie Laughrun, MPH (c.) & Casey Cooper, BSN, MBA
A Master’s Paper submitted to the faculty of
the University of North Carolina at Chapel Hill
in partial fulfillment of the requirements for
the degree of Master of Public Health in
the Public Health Leadership Program
Spring, 2020
Approved By:
Ameena Batada, DrPH
Introduction
Highway 441 into Swain County, North Carolina, is a five-lane highway cut through a
rural pastoral landscape that becomes more commercial the closer you get to the town of
Cherokee. Just on the outskirts of the main street, the Cherokee Indian Hospital (CIH), a 20-bed
hospital and outpatient services facility, sits atop a knoll overlooking the community. The
facility faces Rattlesnake Mountain, which according to Cherokee Elders, holds ancient healing
powers (Ridderbusch, 2019). Now serving over 12,000 members of the Eastern Band of
Cherokee Indians (EBCI), the facility opened in October 2015 replacing the previous facility,
which lacked the capacity to meet the needs of the community. The new facility expanded
access to more outpatient and diagnostic services,
such as: specialized dental services and oral
surgery; outpatient colonoscopies and
endoscopies; a drive-through pharmacy; new MRI
and CT equipment; eye care; hospice, and
improved physical therapy (Kays, 2015). The new
hospital has received national recognition for its architecture and patient-centered design. The
Learning Objectives
1. What is the history of healthcare within the EBCI? 2. What are the cultural traditions of the EBCI?
hospital’s primary funding came from gaming revenue generated by the local tribal casino, an
opportunity that is not available to all tribes.
Historic Context
Within the United States government, Indian health was managed by the War
Department until 1849, before transitioning to the Office of the Interior. Consistent with the
numerous historical injustices American Indians (AI) suffered
as a result of federal policy, the government focused on
tracking where and how many AI were in North America rather
than providing healthcare or tracking health statistics.
Throughout the second half of the nineteenth century and the
beginning of the twentieth century, Euroamerican doctors
declared American Indian medicine and healing practices as
uncivilized to the Office of the Interior. This focus on
“Western” medicine shaped healthcare policy and led to the
education of AI in white-dominated medical schools, which
disregarded Cherokee faith and culture (US National Library of
Medicine, 2012). During this time, babies and children were
removed from their families and forced into orphanages and
boarding schools so they could be indoctrinated with the
mainstream white American culture. Though some of the
boarding schools were used as training facilities to prepare
American Indian women to move into training as regular
A lesson in
adapting white
medicine that
can be applied
to all tribal
cultures
"If Western medicine is to help and not harm the Navajos, it must get them to accept our pertinent and practical knowledge without undermining their faith. Their faith must not be ruthlessly attacked simply because it offers some obstacles to
medicine. Instead,
Western medicine should be expressed to the Navajos in terms of their own culture, in ways that accord with their
understanding of the
world and their values. If a public health worker wins the friendship of a few Navajos and takes time to listen to them, he will learn much that will be of practical use in adapting treatments, procedures, and teachings to the Navajos.”
4
nurses, most of the institutions were plagued with sub-standard living conditions that fostered
health problems. At the time, American society at large thought forcing AI into mainstream
white American medicine practices to be in their best interest, but that notion has since been
challenged: health cannot exclude culture. As evidenced in the literature, including this excerpt
from “Orientation to Health on the Navajo Indian Reservation: a Guide for Hospital and Public
Health Workers”, the exclusion and disregard of culture contradicted curative efforts.Failure to
realize and respect the American Indian culture contributed to the privileging of Western
medicine over other forms of health and health promotion, resulting in American Indian
members’ mistrust. The health services administered during this time by the Office of Indian
Affairs was often inadequate and removed patients from their communities to be treated,
ignoring American Indian cultural elements of health and healing. However, the 1920’s-1940’s
brought about a period of reform as a result of the Meriam Commission, an initiative of
inspecting American Indian programs administered by the Office of Indian Affairs, which
exposed the substandard living conditions of American Indians as a result of government
inefficiencies and severe lack of funding. This reform led to the several key policy changes
including the participation of American Indian medicine men in federal health programming
(see Appendix) (US National Library of Medicine, 2012).
The government’s approach to providing healthcare for AI was among a series of many
events that contributed to the mistrust of American society. As white settlers moved into the
areas that were historically home to the Cherokee, conflicts over land and other alliances
sparked war in 1760-61, during which a significant number of Cherokee were killed (Anderson
& Wetmore, 2006). Increased contact with European settlers and enslaved Africans resulted in
adapting white
medicine that
can be applied
to all tribal
cultures
"If Western medicine is to help and not harm the Navajos, it must get them to accept our pertinent and practical knowledge without undermining their faith. Their faith must not be ruthlessly attacked simply because it offers some obstacles to
medicine. Instead,
Western medicine should be expressed to the Navajos in terms of their own culture, in ways that accord with their
understanding of the
world and their values. If a public health worker wins the friendship of a few Navajos and takes time to listen to them, he will learn much that will be of practical use in adapting treatments, procedures, and teachings to the Navajos.”
an outbreak of smallpox among the Cherokee in 1738-39 and in 1759-60, which led to the
death of nearly half of the tribe’s population. Due to the extent of the epidemic and the
government’s practice of forced removal, entire Cherokee communities were displaced, and
white settlers took over their land. The battles with European settlers and land cessations
culminated with the Trail of Tears in 1838-39. The tribe that occupied the southern Appalachian
Mountains was forced to relocate from North Carolina to the area that is now known as north
eastern Oklahoma by the U.S. government under President Andrew Jackson through the Indian
Removal Act. Families became separated, never to be reunited again, and over 4,000 people
lost their lives. The 300-400 Cherokees who resisted removal, hiding in the mountains of
western North Carolina, were recognized in 1868 by the federal government as the EBCI, the
only federally recognized tribe in the state. The EBCI continued running much of its own
government from this point forward.
The Dilemma
In 2002, the CIH, managed by the Indian Health Service (IHS), was in financial crisis and
was seeing increasing rates of chronic disease in the population, such as diabetes and
cardiovascular disease, that resulted in an increased demand for healthcare services. During
the decade leading up to this point, the health system had suffered from frequent leadership
changes and relatively flat federal appropriations which left the system underfunded and
unable to meet the increasing need for services. Further, the financial and organizational
constraints of IHS created barriers for the local health system operators to design a system that
could align resources to meet the community’s needs. As a result of these issues, customer
community, ultimately leading to underutilization of primary care and overutilization of the
emergency department.
As this situation escalated, the Cherokee community became divided over a
controversial topic: whether to take over the health system that was in financial crisis. Though
the Snyder Act and the American Indian Healthcare Improvement Act (see Appendix)
established the mandate and funding for the federal government to provide health care for AI,
the health system in Cherokee was grossly underfunded and unable to make needed changes to
improve population health. Taking control of the health system was a controversial topic due
to the financial risk, the need to transform the perception of the health system within the
community, and this being the first possible program to be operated under Tribal
Self-Governance within the EBCI.
Tribal Self-Governance provides a legal framework for tribes to exercise their inherent
right to govern and to protect Tribal citizens, lands, and resources. Further, tribes may become
federal contractors to provide services for a given service unit (clinic or hospital), giving the
tribes greater flexibility in allocating resources to meet local health needs. Tribes operating
under Self-Governance may also have access to partnerships with private-sector health
insurance, larger health systems and grants, which are limited under IHS (Ridderbusch, 2019).
Approximately 70 tribes nationally were operating under Tribal Self-Governance at this
juncture. Today, more than 350 Federally-recognized tribes and consortia operate
Self-Governance programs and 20% of federally recognized tribes have taken full control of their
By just one vote, the EBCI voted in favor of taking over the health system. As Casey
Cooper, BSN, MBA the tribe’s Public Health Director, assumed the role of hospital CEO, he had
to correct the health system’s failing financial performance, redesign
the health care delivery system, and regain community’s trust of the
Cherokee healthcare system. From the outset, Casey’s vision was to
align health resources with the true needs of the community. To do
this, the health system needed to become the investment of choice
for Tribal leadership. Becoming the investment of choice for Tribal leadership would provide
financial security but required the health system to become the health care provider of choice
for the people. The greatest challenge in becoming the provider of choice was how to
overcome the legacy of negative relationships between patients and the federally operated
health system, which tribal members felt had not served them well. With no cash reserves, the
CIH leadership team had to act quickly to implement dramatic changes in order balance the
budget and avoid having to cut services as a contingency plan. Changing this trajectory would
not be easy, given the community perceptions of the health system following over a hundred
years of inadequate health care provided by an unresponsive and often adversarial federal
Learning Objectives
1. What is the history of Tribal Self-Governance?
2. Find examples of other tribes operating under self-governance. How did they approach this transition and what successes/lessons did they encounter?
3. Are there other examples of tribes that faced similar challenges of redesigning their health systems? How did they do it and were they successful? Why or why not?
4. Who are the stakeholders and what do they need to know about the decision? 5. What is a federally recognized tribe and what are the implications?
government. What could hospital administrators do to achieve their goal of becoming the
provider of choice for tribal members?
First Steps
In 2006, the health system received the first appropriation from the Tribe, largely
supported by gaming revenue, which created the financial stability needed in order to focus on
becoming the provider of choice for the community. To understand how to become the
provider of choice for the people, the health system conducted community focus groups to ask
people what quality health care looked like to them. Overwhelmingly, the respondents
equated quality with the relationships they had with their providers and care teams. People
viewed their care as being of high quality when they had a relationship with their nurse or other
care team member such that they could call and speak with them personally about their
concerns. Poor quality was attributed to an absence of relationships, resulting in a hesitance to
reach out to their care team. Thus, CIH started building a culture around the third guiding
principle, “Ni hi tsa tse li” (nee hee zah zay lee, or nee hee ja jay lee), or “it belongs to you”, to
create a sense of ownership of the health system by the people it serves.
Over the next four years, Casey and his teams focused on service. While there was no
single expert among the team members, they were able to leverage and build upon the skills
and experiences of team members and community resources. The health system studied the
tribal casino to learn about organizational design centered around customer service. The
the teams spent time evaluating how to change the physical space to create a more
customer-friendly experience.
To improve the customer experience, murals depicting Cherokee lore or local landscape
replaced blank walls and culturally irrelevant wall coverings. Waiting areas were updated with
softer lighting and more comfortable seating to create a more inviting and hospitable space.
During this time, the team also worked to reduce long wait times of up to three hours in the
pharmacy. The team used a variety of tools to identify the bottlenecks in the pharmacy
processes, and to design interventions that decreased the amount of time between the patient
presenting for a service and the patient receiving the service (also known as throughput).
Literature including The Goal, which examines the theory of constraints, and research on the
anxiety of waiting, provided a framework for the team to identify opportunities to improve the
processes. Rapid PDSA cycles (Plan, Do, Study, Act; a continuous quality improvement
technique) were used to design, implement, and evaluate solutions.
While the team was hard at work improving the customer experience, they were
concurrently working to improve quality in terms of health outcomes. CIH joined an
Innovations in Planned Care initiative sponsored by the Institute for Healthcare Improvement
and IHS aimed at improving health disparities and chronic conditions among American Indian
and Alaska Native populations. This was a multi-year venture that connected the CIH team with
colleagues from across the country who were on similar journeys of improving health care
quality and outcomes at their facilities. The Cherokee health system team participated in group
Crisis in the Emergency Department
In 2010, strategic planning for the health care system was put on hold as the board
directed him to focus efforts on the hospital’s emergency department (ED). ED wait times had
reached unacceptable levels because of barriers in accessing primary care. It was difficult for
patients to get an appointment for primary care when needed, patients were often scheduled
with providers they had never seen before, parking was a challenge, and there were too many
“move and wait” processes. As a result, patients were avoiding primary care services and going
to the ED. The tribal leadership was inundated with complaints.
The CIH leadership team drew upon the lessons learned from the pharmacy project and
tapped into new resources to support his teams in evaluating and implementing process
improvement initiatives. A multidisciplinary team traveled to Boston to study ED wait times at
the Institute for Healthcare Improvement, the organization that was hosting their Planned Care
initiative. Upon returning from Boston, the team launched an improvement initiative. After a
year of tracking progress and evaluating the outliers each month, the team had successfully
remediated the issues in the ED. Hospital administrators were able to shift their attention to
Learning Objectives
1. What is human-centered design? Provide examples.
2. Is there data to support customer experience priorities from the patient’s perspective? Does this vary among cultures? Are there consistent themes among various cultures?
3. What strategies have been implemented in other settings to improve culturally relevant care?
4. Are there nationally accredited organizations that focus on this work and offer resources to providers and health systems?
Redesigning Teams and Space
By 2011, efforts to improve quality and patient experience were so successful that the
health system had outgrown its space. Plans to construct a new facility presented an
opportunity to further enhance the models of care through a patient/family centric design. To
begin the planning process, the team once again sought a subject matter expert and discovered
the South Central Foundation (SCF). SCF, a member of the Alaska Native Tribal Health
Consortium (ANTHC) is an Alaska Native-owned nonprofit healthcare organization that fostered
a “total system-wide transformation of care, increasing the quality and adaptability of programs
—and more importantly—the accountability of providers and customers alike (South Central
Foundation, 2020).” Prior to their transformation, SCF’s primary care network had faced many
of the same challenges CIH was facing. In 1999, SCF and the ANTC entered into a joint
operating agreement, and took over ownership and management of the entire Alaska Native
Medical Center. Like the Cherokee system, SCF’s mission was to design a system based on the
needs of the people but it was plagued by access issues and the adverse effects of
intergenerational trauma on population health and stress physiology within the native
populations they served. Additionally, the two organizations shared an interest in designing a
healthcare system around relationship-based care and the ability to do this work under
self-determination. As Casey and the team studied SCF’s work, he thought, “this is it, they’re just
like us.” In 2012, a CIH team consisting of board members, leaders, providers and front-line
caregivers flew to Anchorage, Alaska, to observe care models and receive training at SCF.
There, the teams observed patient-centered integrated care modules which they brought home
culture with quality improvement methods through compassion and empathy. Armed with the
training and tools to redesign processes and a vision for the future, the team returned to
Cherokee to dismantle and redesign the physical spaces and culture of care structures that
defined their current care models.
After seeing the work at SCF, the team realized they had to literally tear down walls to
achieve the integrated care model the team was pursuing. To manage this type of change
when healthcare professionals were accustomed to private offices, Casey recruited Dr. Mary
Ann Farrell to lead the charge as the physician champion. Dr. Ferrell was deeply impressed with
the work at SCF and committed to bringing the model back to Cherokee. The team studied the
details of patient flow and what physical layout was required to support efficiency by visiting
additional model sites. The organization initiated an intense series of PDSA cycles in which they
would mockup, implement, evaluate, and revise new processes until they had designed a
process that achieved their goals. Physicians and other high-ranking positions would no longer
have private offices, the office manger’s role changed, and the care management team was
dismantled and redeployed under the new model, which were challenging transitions.
Learning Objectives
1. What is implementation science and how might a team approach making such drastic changes within an existing team and structure?
2. Who are the stakeholders and what is a strategy for engaging each?
3. What evidence exists to support the concept of the patient-provider relationship influencing health outcomes? Are there models of care used in other settings that include this concept and how do they do it?
Organizational Culture and Values
While the team focused on redesign of the
technical and physical aspects of their work, Casey turned
to bring clarity to the organizational culture. Through a
partnership with North Carolina State University and
Mountain Area Health Education Center, they studied the
Baldridge Foundation framework (see Appendix), known
as the gold standard for organizational performance excellence, and Patient Centered Medical
Home, a team-based care model that facilitates partnerships between patients and physicians.
Core values and concepts are the foundation of the framework. When core values and
concepts are embedded into systems and processes, the organization can realize its goals. This
framework provided CIH leaders with the tools to organize, develop, document, and package
the vision for the organizational culture to support their goal of becoming the provider of
choice. The present-day Guiding Principles, Core Purpose, Mission, Vision, and Values (see
Appendix) of CIH are products of this partnership. The guiding principles were developed with
input from Cherokee elders and founded on cultural beliefs around relationships and how
people interact with and treat one another. The Core Purpose centers around the Cherokees’
cultural belief in the obligation to insure the health and prosperity of the next seven
generations. The Mission, Vision, and Values describe how the health system partners with the
community to provide quality-focused healthcare in a patient and family-centric manner
through integrity, excellence, engagement, stewardship, group harmony, compassion, and
concepts into the everyday work. As a result, the Cherokee Right Way Training (see Appendix)
was developed.
The Right Way training proved effective in building trust and fostering relationships
between the patient and the care teams, which ultimately led to improved health outcomes.
The thought behind this approach is that when patients are sick enough that they need to be in
the hospital (high acuity), they have the least amount of control in that situation and the
relationship with their care team is less important than assuring quality clinical care. However,
when the focus is on prevention, the patient’s level of control is high and that is when the
relationship with the care team is most important and most effective at helping them achieve
health goals, as illustrated by the graphic in Figure 1. Coupled with the culture of continuous
quality improvement (CQI), the implementation of the core values and concepts through Right
Way Training
helped the
patients and the
health system
meet their goals.
As a result of their
work, the CIH
team received
notable
recognitions,
A New Facility
To promote a sense of comfort, belonging, and healing in the new hospital, the
governing board tasked facility design planners with including design elements that accentuate
the natural environment and incorporate elements of Cherokee culture. This directive emerged
from a series of community meetings where tribal members were asked what they wanted to
see in the design of the new facility. As a result, cultural influences can be detected in every
aspect of the design (see Appendix). Signage at the road and throughout the facility includes
both English and Cherokee syllabary, which a group of Cherokee elders helped to translate. The
hospital’s third Guiding Principle, “Ni hi tsa tse li” or “It belongs to you”, is inscribed on the wall
at the facility’s main entrance and is a symbol of the hospital’s mission to serve community. A
reflective glaze coats the exterior windows and reflects the natural surroundings. Walking into
main entrance, visitors pass through a structure that resembles a
hand-woven basket, an item that was commonly used in farming
and gathering. A basket on display just
inside the main entrance is a basket woven by community member, Maddie Wildcatt. The
flooring throughout the main hallways is made of terrazzo inlaid with
nature elements such as a flowing river and native animals, and symbols
Conclusion
Systems are dynamic and non-linear, which often requires a series of iterations to come
up with effective solutions. Multiple stakeholders must be involved to inform the definition of
the problem and provide input for solutions. A team approach helps to generate engagement
and buy-in from primary stakeholders who are directly impacted, and often doing the work
needed to support the change. It is not only what you do, but how you do it. This case study of
how the EBCI transformed their health system, and as a result, the health of the community
illustrates the need to merge empathy, culture and trust with principles of CQI in designing
health care systems and solving for systems issues.
Learning Objectives
1. What principles demonstrated by Cherokee Indian Hospital might be applied to any restructuring of an organization?
Appendix
Cherokee Indian Hospital Design Photos
Use of Cherokee syllabary on signage (Ridderbusch, 2019)
Maddie Wildcatt’s inspirational basket (Christensen, 2018)
Water spider inlay in the floor at the main atrium; symbolizes the legend of how fire came to Earth (Cherokee Indian Hospital Authority, 2019)
Policy Timeline
• 1921: Snyder Act (Warne, MD, MPH & Frizzell, PhD, 2014)
• Congress authorized funds for American Indian Health Care
• First law that allowed Congress to appropriate funds on a recurring basis
• 1942: Seminole Nation v. United States (US Department of the Interior Indian Affairs,
n.d.)
• Solidified the Federal Trust Responsibility as the legally enforceable financial
obligation of the United States to protect tribal treaty rights, lands, assets, and
resources, as well as a duty to enforce federal law with respect to American
Indian and Alaska Native tribes and villages
• 1954: Indian Health Transfer Act (Warne, MD, MPH & Frizzell, PhD, 2014)
• Shifted responsibility of Indian health from Bureau of Indian Affairs (BIA) to the
newly created Indian Health Service (1955) under the Department of Health,
Education, and Welfare's Public Health Service
• Recognized tribal sovereignty and afforded a degree of tribal self-determination
in health policy decision-making
• Shifted focus to increase research of the condition of AI health care and
construct hospitals
• 1975: Indian Self-Determination and Education Assistance Act (Warne, MD, MPH &
Frizzell, PhD, 2014)
• Established a legal framework for tribes to exercise their inherent right to govern
and to protect Tribal citizens, lands, and resources
• Authorized the tribe to assume management of health services and any
program, function, service, or activity of the IHS or to continue to receive health
• Directed the Secretaries of Interior and Health and Human Services to enter into
self-determination contracts at the request of any tribe
• Allowed tribes to become federal contractors to provide services for a given
service unit (clinic or hospital) under a block grant for a total budget amount,
giving the tribes greater flexibility in reprogramming resources to meet local
health needs
• 1976: Indian Health Care Improvement Act (Warne, MD, MPH & Frizzell, PhD, 2014)
• Declared the United States’ responsibility to maintain and improve the health of
AI people
• Permitted IHS to bill Medicare and Medicaid, which resulted in ongoing
expansion of services
• 1988: Indian Gambling Regulatory Act (National Indian Gaming Commission, 1988)
• Established the National Indian Gaming Commission and the regulatory structure
for Indian gaming in the United States
• Not less than 60 percent of the net revenues is income to the Indian tribe
• Net revenues from any tribal gaming are not to be used for purposes other than
to fund tribal government operations or programs, to provide for the general
welfare of the Indian tribe and its members, etc.
• 1994:Indian Self-Determination and Education Assistance Act Amendment
(Congress.gov, 1994)
• Added a new title on self-governance
• Directed the Secretary of the Interior to carry out a program known as Tribal
• Annual funding agreements with tribal governing bodies in a manner consistent
with the Federal Government's laws and trust relationship to and responsibility
for the Indian people
• 1997: Eastern Band of Cherokee Indians opens video poker parlor, the beginnings of
Cherokee Indian Hospital Guiding Principles (Cherokee Indian Hospital Authority, 2019)
The guiding principles were developed with input from Cherokee elders and represent cultural beliefs around relationships and how people treat one another.
U wa shv u da nv te lv (oo wa shuh oo da nuh tay luh) The one who helps you from the heart
CIHA believes that care and service delivered most effectively is delivered
from the heart.
To hi (toe hee)
A state of peace and balance
CIHA believes “to hi” can only be achieved through healthy relationships and is fundamental to living
healthy lives.
Ni hi tsa tse li
(nee hee zah zay lee, or nee hee ja jay lee) It belongs to you
CIHA believes that all health care services belong to the people and CIHA is a steward of their inheritance charged with safe guarding it and providing it to them when and how they need it.
di qwa tse li i yu s di (dee gwa jay lee ee you sdee)
Like family to me
CIHA is committed to being the healthcare partner of choice for this community and enjoying the
Cherokee Indian Hospital Core Purpose, Mission, Vision and Values (Cherokee Indian Hospital Authority, 2019)
The Core Purpose, Mission, Vision, and Values, describe the health system’s commitment to the community and its culturally relevant approach to promoting health and wellness, and taking care of the people it serves.
Core Purpose
To enhance the prosperity of the next seven generations of the Eastern Band of Cherokee Indians
through relationship-based healthcare. Daily we strive to reach the highest standards of national healthcare and deliver
them locally.
Mission
The Mission of the Cherokee Indian Hospital is to be the
partner of choice for the community by providing accessible, quality-focused, patient- and family-centered healthcare, while responsibly managing the Tribe’s resources.
Vision
Our vision is to be significant in the lives of Tribal members, educating and leading them to
their healthiest, happiest lifestyles. We will offer healthcare excellence that
exceeds our patients’ expectations, always seeking to
improve the health and well-being of the Eastern Band of
Cherokee Indians.
Values Integrity, Excellence, Engagement, Stewardship, Group
Right Way Training Framework (Cherokee Indian Hospital Authority, 2019)
The Right Way Training is a three-day training provided to all new hires. The curriculum teaches team members the importance of demonstrating empathy and compassion in their interactions with patients and with each other and provides them with the skills to do so. The Core Purpose and Guiding Principles are instilled in trainees, along with the expectations of upholding these values through their interactions with others.
Baldridge Framework (Baldrige Performance Excellence Program, 2015)
References
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Self-Governance Communication & Education Tribal Consortium. (2020). Self-Governance FAQs. Retrieved January 19, 2020, from Self-Governance Communication & Education Tribal Consortium: https://www.tribalselfgov.org/self-governance/faqs/
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