 My work at Maple City Health Care Center to foster a healthy community within the staff and in our neighborhoods is rooted in and an Outgrowth of a formative house church experience. I had in the 1970s In the very neighborhood in which the health care center is now located My idea is about what a healthy community would look like one that bridges socio-economic and cultural divides was shaped by my experiences of church and My ideas about the church. I went off to medical school not primarily to become a doctor But to explore how health care a much needed service in that community might function as an entry point to engage in these bigger questions of Creating a space for healthy community to happen Now from the beginning the health care center was grounded in a vision for how to foster Relationships and community in the neighborhood and we could apply that vision to the many day-to-day decisions about what to do in Ways that were intuitive and that worked in a small organization where we all knew each other and Organizational culture was driven and sustained by charismatic leadership But over the past 10 years We've grown from one site and a staff of about 20 people to two plus sites with a staff of 130 and With those rapid changes and growth We've realized that we had to be more deliberate and intentional about fostering and supporting organizational culture So let me tell you a little bit about what we look like now We have two main sites one an old fire station the other a mansion We have a house next door to the one where groups gather and a dental house next door to the other Our patients are 60 plus percent Latinx many of them undocumented Over 80% of our patients have incomes below 200% of federal poverty level and qualified for discounts and 45% of our patients are 18 years of age or younger Our staff includes three family physicians nine nurse practitioners two midwives a dentist for behavioral health counselors a psychiatrist and addictions Counselor diabetes educators pregnancy care coordinators nurses nutritionists social service coordinators dental hygienists dental assistants Navigators who do financial assistance and lots of other support staff in billing and medical assistance from a front office work and administration We also have a program using lasers to help ex-prisoners with tattoo removal All of our services are available on a sliding fee scale We've never used collection agencies and now we no longer track debt if chargers are not paid they disappear We do encourage all patients to think about what they can contribute to our community And we're happy to recognize those contributions as payments for health care and in the pre-covid days We spend a lot of time Together eating so back to the kind of culture. We're trying to foster I think there are some parallels between our more deliberate efforts to foster a sustainable organizational culture that is profoundly counter cultural in the broader medical environment and Christian catechesis We are after all inviting people to be a part of a different kind of community with with different values and different ways of being engaged with their co-workers and their neighbors and We want them to thrive in this different dynamic environment And so we want to help them think clearly about what we're trying to do together We are wanting to nurture right thinking something you might in your religious context Think of as orthodoxy We want to help people develop habits and practices that sustain our alternative engagement in the world in our community parallel perhaps to orthopraxy and We want to encourage people in aligning their passions and their stories of who they are and what they are about with an alternative story Sort of like orthopathy So as I share a bit about the ways we work to develop and sustain culture I invite you to reflect on how these efforts fit with right thinking right practice and right passion in your context now the mission of maple city health care center is to foster healthy community in our neighborhoods by providing and promoting affordable accessible integrated quality care and To articulate and promote our experience as a sustainable model And our core values are long-term relationships with patients and in the staff and in the community and integration of care of teams and staff and Personal integration that the job fits with who you are and what you want to be and Thirdly empowering people for shared work as we think about operating principles that can help sustain us in our culture There are three broad areas. We talk about number one fostering a community of sufficiency and abundance to Fostering a work environment of innovation of imagination and shared risk-taking and three fostering a culture of excellence So first fostering a community of sufficiency and abundance This is one that I think needs to be sustained by spiritual practices practices of gratitude and hospitality We have lots of shared meals and we frequently have story circles that focus around stories of gratitude We also make a practice of trying to think about things that others might think of as barriers And think of them as assets one of them being our multicultural environment both in terms of patients and Staff We frequently actually recruit staff from within our patient Population It's not uncommon for us when we need a new medical assistant instead of advertising in and and looking at selecting from among applicants to instead think together About who is a patient who? Already exemplifies the kind of values that we care about in their engagement with their family in the community And then we will go to them and say, you know, we know that you may be employed in a in a trailer factory or whatever But we really would like you to join this important work that we're engaged in here and join our team Would you please? Consider our invitation and rarely are we turned down We organize our finances our salaries and our benefits around sufficiency We want to make sure that everybody has a living wage So, you know, it's not easy to raise a family on what a receptionist or a medical assistant makes in Goshen, Indiana So all of them get paid more than what they would otherwise get paid in the marketplace And it's very easy to raise a family are half of what a physician makes in Goshen, Indiana So our physicians get paid about half of what other physicians in the community are paid So we have this very squished salary scale And then we still have You know a single mom with five kids who even though she's getting paid about market rate is still living in poverty And so that family will get a third check every month to bring them to a living wage We have benefits that we don't think of as some kind of deferred compensation where everybody gets exactly the same but rather Where we're trying to look at what are the basic things that we want everyone Among us to have access to whether it's health care or dental care Retirement help with childcare help with sending kids to college Paid parental leave on the arrival of a new child emergency assistance So One of our our employees I'll call her Maria Was born in Mexico and brought to this country as a young child by her parents And grew up in Goshen. She married an American citizen and had two children who were American citizens But she was undocumented and she was working for us and at a certain point Decided she really was tired of living in the shadows and wanted to go back to Mexico to apply for Documentation so she could come and live in this country with her family with documents She was told it would probably take about six months to get this taken care of and so she went off to Mexico And she ended up being stuck at the border for two whole years waiting for her papers to go through During this entire time we held her job for her We had a big sign in the front office that's with her picture that said Maria is coming back And during her time there at the border we had staff who went down to visit her. We kept her family on our health insurance program and continued to be in touch with her When she finally got her papers and was traveling back to Goshen driving the last leg from Texas She arrived in Goshen at eight in the morning and she Ended up at our doorstep waiting for her family at Maple City Health Care Center to come in for the day to greet us and Rejoin us did that even before she went to visit her mother and father She's One of these people where we have worked at Trying to find ways to make sure that everybody has enough That those who have much do not have too much and those who have little do not have too little our second big category of organizing principles is to foster a work environment of innovation of Imagination and shared risk-taking and this one depends so much on having to start with a culture of sufficiency because if there's not sufficiency invariably people are afraid that there's not enough for them and the first Casualty of a fear is always imagination. So if we want imagination and innovation We have to make sure that people have enough one of the big tools we use to foster a Culture if you will of of imagination is our circle model of of Working together we we try to have all kinds of engagements whether it's one-on-one or Administrative team or staff meetings or huddles or hubs or various parts of the organization or the board meet in circle where we try to listen carefully and make sure that we are creating a context where Imagination can shine through We have five agreements that we hold to when we are in the circle arrangement The first is that we will honor the trust we place in each other as we share our stories a second is that we will speak for ourselves with Focus with intention on our shared work A third is that we listen with curiosity and compassion and suspend judgment Fourth is that we offer what we can and we ask for what we need and lastly and importantly from time to time we take pauses sometimes we take a pause to Mark transitions or to mark the intensity of emotion in a particular moment Sometimes we take pauses to refocus our our thoughts and our conversations Sometimes we take a pause because we just don't know how to proceed So these circle agreements in these ways of working together Help foster a culture of imagination and shared Innovation I'd like to tell you a little bit about our board, but first I want to tell you about our pregnancy circles One of the first things that happened at the health care center was that we had prenatal education to women who were doing Prepared childbirth classes in our community one of them was lowest Kauffman whom you may know Approached us very early on and said, you know the people who need this the most our low-income folks and so on Don't tend to be part of our groups And we're wondering if we can collaborate and we could do our groups at your space and in exchange your Patients could be part of these groups at no cost and so we worked this out and we started having people there And what we found was that pretty early on our Latina patients did not end up going to any educational groups or classes They just wouldn't show up they always show up for their medical appointments, but they wouldn't show up for the other stuff We tried all kinds of things. We tried bilingual classes. We tried Spanish only classes We tried to arrange a schedule so that their their medical appointments would align with these class schedules Nothing seemed to work. And so eventually we decided we really needed a different kind of model for prenatal care and we looked to a group that was starting a model that's since become a national model called centering pregnancy and they were doing this at Yale and the midwifery school there and What we do there is we have six to eight women who are do it about the same time They form a cohort a group and they meet for a couple hours about eight to ten times during their pregnancy And the first hour half hour is your typical medical kind of stuff We check their blood pressure and their weight and we listen the baby's heartbeat and make sure the baby's growing all those kind of medical things and then the last hour and a half they spend together in a circle talking about the things that are important to them during this pregnancy and invariably they're talking about labor and delivery and new baby issues and family issues about How to accommodate this new child and relationships with their partners and how those change during pregnancy and and various things And the support that they're going to have during labor Now we had Spanish language groups like this and English language groups like this and as our Pregnant population increasingly became a Latinx population Latina population We started getting to the point where we didn't have enough women to sustain our English speaking groups And so we were thinking do we want to drop this? Well, not really. You're not based on language. So we Called the folks at Yale and we said what what do you guys think about us doing this with with interpreters? And they said oh, it's gonna slow all the content down so much. We really would discourage it We don't think it's gonna work So we took their advice seriously and decided to try anyway and we did it with a really good interpreter and Whenever somebody would say something in English it would be repeated in Spanish for the entire group And whenever anything was said in Spanish it would be repeated in English for in the entire group And all of a sudden people could only say about one breath's worth before they would have to stop for the interpreter and they started speaking with greater care and with greater passion and Communicating tender things to this group in these cross-cultural contexts. It became just an incredibly rich experience of talking about How we think about breastfeeding in a Latina culture versus an Anglo culture of what kind of foods people think about is being okay to eat during pregnancy or to Support breastfeeding How they've dealt with issues of violence in their families How the relationships have changed in the course of praying what kind of support they have I mean here We often have women who are used to having babies in a context of lots of support from Grandmothers and a mother and and some aunts and all of a sudden they find themselves in a context where they only have maybe if they're lucky reliable support from a partner And so this group became a kind of support group a cross-cultural support group for these women some wonderful experiences Back to my board our board Early on our board was made up of lots of low-income folks from the neighborhood most of them patients almost all of them patients who Drew largely from two groups one was a tenants organization that was working on trying to help the city develop a minimum rental housing standards Especially in response to a local Mennonites long lord and the other The local parent-teacher organization at the elementary school across the street from us and these Low-income folks got very involved early on in trying to renovate the old fire station a knocking down walls and building new walls and having hillbilly hot dog sales and bake sales to try to raise a little bit of money for it and and all that kind of stuff and then as we got more mature as an organization and Became a 501 C3 tax exempt not for profit These the roles of the board became increasingly clarified in traditional ways as being about Administrative oversight and fiscal oversight and policy oversight and these were such middle-class categories and So our board continued to be made up of patients But gradually our low-income folks drifted away and the board was increasingly a group of white middle-class Mennonites wonderful people very supportive patients, but More monolithic than we would have hoped and one day I was writing a grant application something I don't usually do for inspiration and One of the questions on the grant application was so how is the diversity of your community reflected in the diversity of your board? And it was like oh ouch so We started looking systematically at how could we reorganize we're in our organization is Cross-cultural stuff really happening the best and we came to realize it was happening the best in these pregnancy groups And so we went about deliberately trying to figure out how do we reorganize the board in the image of a pregnancy group? We invited a bunch more people and we went to our our our super supportive white Mennonite board members And we said we need you to be part of this But we need you to be part of a bigger thing and a more diverse thing Would you please join that new board and then we invited low-income folks and Latinos and developed a much more diverse Board but then the question was how do we arrange our agenda in ways that don't just drive all these people away again as if we keep doing the Same thing that that that led to their alienation to start with and so We thought about what is it that makes the pregnancy groups really work? Well, it's story These are women who are telling their stories and so we organized our Board as in a circle process and that we we tend to meet always on a Tuesday Evening at seven o'clock people are kind of tired already and as each new person comes in they Pick up some food we always have shared food and they go around the circle and Greet every person that's in the circle and then we spend the first hour of our group time together in a story circle And we have we choose one question for the evening and each person tells a story around that same question And it can be a question like tell us about a time when you Were in crisis and what you learned about yourself or tell us about a time when you experienced unexpected hospitality or tell Us a story about how money was handled in your family of origin And we learn a lot about people's passions and their convictions and what they care about and what they're afraid of and what their What kinds of risks they're willing to take and then the second hour of our meeting is all about housekeeping It's doing taking care of the budget and the policies and all the other things that the board needs to do And it happens very quickly and very efficiently because we have deep Relationships of trust and understanding that have all developed in this cross-cultural Context with interpreters English Spanish bilingual figuring out Who we are together as a community and what our shared story there is another thing we try to do in terms of creating an Environment for innovation and imagination as we try to focus on shared work We organize our clinical care teams with multi Disciplinary folks all represented sitting in the same area Constantly interrupting each other and working with each other around patient care So the patient care becomes a team effort and it's not just an individual practitioner doing stuff So the particular team I sit in on it on a daily basis includes me as a physician includes nurse practitioner includes a midwife It includes a couple nurses. It includes medical assistants. It includes a behavioral health counselor. It includes a nutritionist It includes an addictions counselor and includes a psychiatrist and we all are working together as a team to Figure out how to address our patients needs so avoiding silos and working in in shared work We try to have clear expectations and structures because we find that the most common reason that that The thing that undermines trust is when expectations are failed and the most common reason That expectations are failed is because they weren't clear and so we try to have clear expectations about structures about communication and about processes We have sort of a what we refer to as a tight loose tight Model for how we do things we want to be tight on vision We want to keep thinking about vision all the time and how does this fit with who we want to be we know by loose on methods and Wide imagination and brainstorming about ways we can do things So we don't always have to do things the same way it's always been done and then we want to be tight on outcomes We want to measure and make sure that what we're actually doing is actually working and we work a lot at developing tools for self-awareness for group dynamics and For a good process. We we have a whole structure for thinking about process that that seeks to make sure that We're identifying the issue the problem in terms of the mission and the vision and so on first and not rushing to solutions Before we are clear together with all the necessary perspectives at the table about what really is the thing we're trying to address So a wide range of things to try to create an environment of imagination and share risk thinking The third broad category is how do we foster excellence? We we try first and foremost I think to to engage the motivation for change in our staff and in our patients so we recognize that we are much more effective if we can Build a context of co-producing value with patients and with staff along the way There's a patient I'm gonna call her Anna who Came in to me she has diabetes it's been poorly controlled She was in a very abusive relationship finally kicked her partner out But let him continue living in the trailer was she owned and she ended up moving in with her sister living on the couch along with her young teenage son Her diabetes was pretty controlled and as I talked with her some I realized that one of the things that she was doing is whenever she was anxious or feeling bad Which she was doing a lot of she would comfort herself by eating Mexican sweet breads Bandulce And her sugar was terrible and she would eat this panduzzi and then she'd feel terrible about having eaten panduzzi feel guilty And like she couldn't do anything right and as she felt increasingly terrible about that she would comfort herself by eating panduzzi and this got in this vicious cycle of eating a lot of panduzzi and Feeling terrible about herself and when you talked about this at some length and at a certain point I asked said you know I I would have a Suggestion if you're interested But you know it's gonna have to be your decision what you want to do and where you want to go with this And she said she was interested and so I suggested That every Sunday morning when she which is her most relaxed day of the week that she deliberately eat Panduzzi That she eat a panduzzi and Savor every moment of it. In fact that she do this as a doctor's order or this is a requirement This is an expectation We we really want you to eat a panduzzi every Sunday morning and thoroughly enjoy it Enjoy every bite of it in fact, I Ended making arrangements to call her every Sunday morning To remind her that this was her day to enjoy her panduzzi And wouldn't you know it a month later when she came back her hemoglobin a1c a measure of her diabetes control had dropped by two points a Dramatic improvement in sugar control that you would not normally expect even with initiation of new therapies or new medications a huge improvement and She was feeling better about herself And enjoying the panduzzi she was eating a whole lot more when she did eat it another thing we work at in fostering a culture of excellence is To seize the moment to seize every opportunity to do the things that make for better health We refer to as carpet DM and part of what it is is that we build these Relationships of trust with our staff and with our patients over over decades And then we leverage those so that when we have an opportunity to do something that actually has been shown to make a difference We actually do it so for example a Woman not that long ago brought in a her son with a sore throat and She wanted us to attend to that and we looked at this sore throat and traded him and so on and then I looked at her Check and I said and you know while you're here you actually are due for a tetanus booster And you're due for a lipid screen and you do for pap smear. So Since you're here, let's just get all that done in the next 10 minutes and then it'll be done You don't have to worry about it. And so she said okay. Now. She said okay, because we had known each other over a long time And she trusted us and She was willing to go there So we we seize the moment. We see every opportunity To do the things that that make for better health Any opportunity that it's not taken is an opportunity wasted and so We we really work at that We work a lot of having high quality data And at being very transparent about that so that everybody can see everybody's data It is timely. It is accurate. It is trended and comparative and above all it is relevant data And so data is really important to us We encourage experimentation in how people work together and the kinds of Things they do so that they develop new models that can then be appropriated by others as well and we really work that at this Interesting dynamic integration of relationship-based care and Data-informed care so that we are using the resources of our long relationships with patients and At the same time being very aware of the data and where it's taking us so that we can maximize outcomes Now of late, we are really working here at developing a curriculum if you will a Curriculum of shared principles shared practices and shared passions a Whole curriculum we call core concepts And we're trying to include all parts of the organization We're using it initially with new staff as they come on board as a way of orientation But also bringing in that old staff and board and patients and administration to really explore all these different building blocks of shared culture in Which we can as we do these things together We can all learn to live into a changing environment in which we can all thrive. I Look forward to further conversations about this later today. Thanks