Revised: January 2019
By Sarah Owens and Michael Livingston
One by Santiam Hospital, the other by Salem Health, both modeled on Polk County's long-standing service integration program. Hopes were high.
Today, however, only one of the programs remains faithful to the model and will continue next year. The other, having relied on shortcuts and cheap fixes, is suspending operations, pending discussions with potential "partners." The fate of this program's individual teams is now very much up in the air.
The story of these two programs, related below, is an object lesson on the danger of short cuts to high-fidelity replication.
The story begins in early 2017, with a group of more or less like-minded individuals who, for a long time, had wanted to bring service integration to Marion County, based on the Polk County model. We were members of that original group, which is how we came to be in a position to relate this story. So was Sharon Heuer, the Community Benefits Director at Salem Health.
|Sharon Heuer conducting info session in Stayton|
By the third meeting, the practical and political problems with developing a team in the Salem-Keizer area were quite evident. It would get too large and end up being just about the money. And, what about the CPTs? The group decided it would be best to start with a rural community, one with unmet needs, but organized enough to want assistance developing a team whose primary goal would be to coordinate the sharing of resources and information. Sharon, however, was really wanting a team near the hospital, so, at some point, it was decided that there would be two pilot teams, one in a rural community, the other inside the Salem-Keizer School District. In March, we issued a request for applications. The RFA went out over the name "Marion County Service Integration Teams." Certain Marion County officials didn't care for that, so the name was changed to "Service Integration Teams of Marion County". April was spent conducting information sessions at strategic locations.
In late July, Sharon announced that Marion County would have four teams, one run by Santiam Hospital, three run by Salem Health. The steering committee had concerns about Salem Health's starting up three new teams all at once, but, Sharon was very confident and insisted it could be done. At the very same meeting, she started talking about "sustainability" and applying for grants. Over the next several meetings, we came to realize that she was talking about handing the program off to some other agency -- maybe United Way, WVCH, the county, MWVCAA, someone -- by the end of the year.
|map as shown on SITs of Marion County website|
Another dynamic we were slow to recognize was that Sharon had a very limited concept of service integration; as far as Sharon was concerned, all the coordinator needed to do was facilitate meetings and send out funding requests. The rest was "SIT magic." What Sharon never seemed to understand is that what she called "magic" was entirely a function of the coordinator's relationships with local providers, knowledge of local resources and ability to assess a situation and coordinate an appropriate response. What Sharon called "magic" was, in fact, all the hard work that must be done before a funding request ever goes to the team. Otherwise, it's not a service integration program -- it's at best a small grants program.
The tension between the two programs began when Santiam Hospital said it wanted its own service integration webpage. That really seemed to irritate Sharon, probably because it interfered with her plan to market service integration in Marion County using the website she was planning to develop. The idea was that "Service Integration Teams of Marion County" (the original name of the website and Facebook page developed by Salem Health, with a domain name, "SITsofMarionCounty") would be a sort of "umbrella" for both programs, with event calendars, resources, and links to forms, guidelines, and other basic information that was supposed to cover all the teams in Marion County.
Trouble was, however, the "umbrella" had Salem Health written all over it, meaning the website was designed and executed in such a way as to make it appear that there was only one program, and it was operated by Salem Health. Things got even more confusing when the Salem Heath coordinator rewrote the funding guidelines and published them without consulting anyone, including the steering committee. We knew then that the program was in serious trouble.
A successful service integration program simply must have an experienced, knowledgeable person to coordinate the teams full time, especially if the program is just starting out. If all that was needed to succeed was someone to facilitate meetings and send out funding requests, then it might have made sense for Salem Health to reassign, on a temporary basis, an inexperienced part-time staff person with no aptitude to the coordinator position. Of all Salem Health's misjudgments and short cuts, Sharon's failure to understand the importance of having a skilled, full-time coordinator was the worst.
|CHEC Support Group Room|
For Sharon, success was all about spending the money. We tried to tell Sharon that the coordinator needed more hours and job shadowing or other training opportunities. She just said everything was fine, except the teams weren't spending the money. She never understood that the teams weren't spending the money because they weren't doing the work, and they weren't doing the work because the coordinator lacked the skills needed to guide them.
Things finally came to a head over the Salem Health website. A 1/31/18 article in the Statesman Journal referred to the Santiam Service Integration program as being supported by "Salem Health's Santiam Hospital." When the reporter was asked where he got the impression that Santiam Hospital was Salem Health's, he said he got the "information" off the Salem Health website.
For months, Sharon had been told that using "SITs of Marion County" on the website and FB page was misleading and the name needed to be changed. Even though the steering committee all had agreed it should be changed, she resisted -- she wanted her "umbrella."
Most managers would have understood what that letter meant, but Sharon acted as if nothing had happened. A week later, she canceled the February steering committee meeting. Two weeks later, the CEO sent another letter, this time spelling it out: Salem Health was to remove all references to the Santiam Hospital program from its website. Sharon ordered the requested changes, but left the name unchanged, saying she wanted to take it to "the regional group." It was only under continued pressure -- from the steering committee and from the resignation of her coordinator, who'd found a full-time position elsewhere -- that she finally relented and ordered the website and FB name changed to "West Marion County Service Integration."
That was pretty much "it" for the steering committee. Sharon said she was "resigning", but of course, it was her committee. She reassigned one of her staff and hired a part-time contractor to cover the vacant coordinator position. Then, in March, she persuaded one of the newer steering committee members (she was always dropping and adding members as suited her need) to call a meeting. She was still wanting help finding someone who would take over her by now very messed up program. Six weeks later, Sharon was no longer with Salem Health. Two weeks after that, Salem Health announced to the teams that the program would be suspended for July and August while they conferred with "partners" about its future and that the teams should look for an announcement maybe mid- to late-August.
So that's the very abbreviated story. Plenty of folks are not going to like this account, but they need to remember, it's meant to be an object lesson on the danger of shortcuts to high-fidelity replication, not a sympathetic account of good intentions, or a comment on the teams or any of the unnamed participants. It's not even a comment on the named participants, though it will seem like it to some. Some will think it's wrong to call out anyone who's ostensibly trying to do good -- that it's "too negative", or somehow unfair. They would have preferred a different story. Fair enough. They are welcome to tell that story and post it, or a link to it, in the comments section. This happens to be a story about serious errors of judgment that affected CANDO and other communities and will continue to affect them, probably for a long time. If we could have told it without specific reference to key figures, we would have.
What makes this a particularly hard lesson is that most of the shortcuts were warned about. Rolling out three teams at once. Reassigning untrained, part-time staff, instead of getting the right person for the job. Blowing off the funding guidelines and accounting practices. Focusing on spending the money instead of working the problem.
Other mistakes were obvious -- including our own. Not making sure everyone understood basic words and concepts before proceeding. Not requiring partners to be committed (and honest). Not attending to concerns raised by partners, especially those about the website.
The big mistake, though, was failing to appreciate how hard it is to replicate a someone else's program. Kevin Starr and Greg Coussa said it this way:
High-fidelity replication is hard. You have to do everything as well as the innovators did. You can’t leave stuff out, make arbitrary changes to methods and procedures, or cut corners just because you didn’t raise enough money. If you do it wrong, it may not work at all. Replication is both a science and a high art: You must be committed to and obsessive about the details.
Epilogue: In the fall of 2018, Salem Health announced it had "identified three new partners to help run and coordinate our teams." With the exception of The Salvation Army, the "new partners" are the original pilot partners: Love, Inc. and the North Marion School District. All are operating separate and apart from each other, and none claims to be attempting service integration. For more on the Salem partners, see "TSA Launches Salem-Keizer Collaboration."