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This podcast episode explores how to design healthcare facilities for specific patient populations, focusing on the experiences of American Indian, Alaska Native, Native Hawaiian, and Pacific Islander communities. The guests include leaders from South Central Foundation, a healthcare organization in Alaska, and an architect from MVBJ. They discuss the reinvention of healthcare systems, the importance of recognizing unique cultural heritage, and the challenges faced by indigenous populations. The conversation also touches on the negative generalizations made by modern epidemiology and the need to consider traditional practices and community interests in healthcare design. Hello, and welcome to Uplift, a podcast about the transformative power of design from architecture and design firm MVBJ. I'm your host, Andy Snider. Each episode, we chat with people from all over the healthcare continuum who have been deeply affected by the built environment. Today, we dig into how to design for specific patient populations through the lens of more than 9 million people in America who identify as American Indian, Alaska Native, Native Hawaiian, or Pacific Islander. We head to Alaska to learn how recognizing a population's unique heritage and culture can be transformed into successful building solutions. To discuss, I'm joined by two leaders from South Central Foundation, a nationally ranked healthcare organization, Dr. Doug Eby, Executive Vice President of Specialty Services, and Monica Lee, Director of Operations, as well as MVBJ architect, Brian Uyusugi. Let's dive in. Welcome everyone. Thank you all for being here. Dr. Eby, I'll start with you. You're the EVP of Specialty Services at South Central Foundation, and you've served on leadership teams at SCF and at the Alaska Native Medical Center for almost 30 years. Can you tell us a little bit about SCF and your role there? Yeah. So South Central Foundation, first of all, we're not a foundation in the usual sense of the word. We are a nonprofit health corporation in clinical service delivery. With a partner, we are a full spectrum vertically integrated system. Our part of the system is our 2,700 employees do everything from primary care, behavioral health, optometry, dental, a big range of maternal child health services, rehab services, and then a bunch of residential treatment and outpatient treatment facilities. So it's a community entry-level population health role. And then we have a partner, the Alaska Native Tribal Health Consortium, with over 3,000 employees. And together we run a almost 200-bed tertiary care hospital with all the bells and whistles and so forth that supports the entire state of Alaska. We're part of a tribal health system in Alaska. Twenty percent of the people in Alaska are Alaska Native. And so it's a big comprehensive vertically integrated network of services across the state. And we and our partners are jointly operating the Alaska Native Medical Center, which is the brand we share, which is the hub of the whole system. Between us, 6,000 staff doing everything from water and sanitation to population health to primary care, maternal child health, and all the way up through ICU, CCU, hospital services. For SCF, we've been on a 25-year journey to completely reinvent health care from the perspective of those who use the system and depend on it. So we refer to them as customer owners rather than patients. And this is a consumer-driven, consumer-owned reinvention of an entire health system, which has resulted in us winning the National Malcolm Baldrige Quality Award twice. And we're the only health care organization in the United States to do that. And you don't get that award by being cute and from Alaska or being Alaska Native. It's the hardest to achieve accomplishment in health care in the U.S. And we're very proud of having done that. And the reason is because complete reinvention and then sustained performance, way better health outcomes at lower cost with way happier people for over 20, almost 25 years now. And I'm also excited for myself. I've been in leadership here over 30 years on the downhill slope to retirement, shrinking my role as fast as I possibly can and shoving all the responsibility, headaches, and loss of sleep to people like Monica Lee, our Alaska Native leaders who increasingly operate every level of the system instead of imposters like me who have been given the privilege to be allowed to be part of this journey. That's amazing, Dr. Eby. Thank you for that introduction. Monica, you work at South Central as well as the Director of Operations. And you also identify as an Alaska Native person. Can you tell us about both your professional and personal experience at SCF? Yeah, absolutely. Hi, my name is Monica Lee. My background is Inupiaq and Korean. My family is from Point Hope and Wainwright, so higher end of the Alaska map. And then my mother's side of the family is from Korea. I started with South Central Foundation in 2011. I have gone through a lot of different professions here at South Central Foundation. Started off in HR, left HR as a Senior HR Generalist, went in to process improvement for the organization, worked with specialty health care system for the improvement piece of it, and now I'm the Director of Operations for the specialty clinics. I am also a customer owner here. I was born at the old hospital, so it's an amazing achievement to see this amazing system that we have right now. The old hospital was an interesting way of getting services. Anytime we had to see a provider, we would go through the emergency room, and we would wait there all day just to see a provider. So I'm very excited to see where we are today and the services that my kids are going to get in the future, my grandchildren, and so on. Other than that, yep, I provide support for about 18 to 19 different clinics, but also support a primary care system by helping them, partnering with them, and like Doug said, the Alaska Native Campus and making sure that we're providing services for our state. Thank you, Monica. A pleasure to meet you. Brian, you're a Principal and Health Care Designer at NBBJ, and you were also born and raised in Hawaii. You've also led many of our projects that focus on design for specific populations. Tell us a little bit about yourself, your design philosophy, and your process. Sure, Andy. You know, I feel privileged to have been born in Hawaii. I'm what they call Hapa, so in Hawaii it's like half, so I'm half Japanese and half Portuguese. I grew up in a small plantation town of Waialua on the north shore of Oahu, where many generations of immigrant families came to work for labor, you know, in the sugarcane fields and such. So I was raised around just a big, diverse cultural background that shaped the view of my world. We all had to figure out how to get along. And through that, this Hawaiian culture was always part of life there. Education, to the music, to dance, was always part of the life. Little did I know back then, having been raised in this melting pot would shape my view of the world and how I would be thinking about design as I grew up and went to college for architecture. Finding, I think, a higher sense of meaning and purpose in the work has always been at the heart of, I think, my process. And I think the more when we find communities and people that are in love with their spaces and buildings, I think that just builds a higher sense of meaning and purpose for me. Thank you, Brian. And thanks to everyone for joining us for this conversation. Dr. Eby, while many indigenous people live happy, healthy, successful lives, various organizations such as the National Council on Aging rank them at the bottom of social health and economic indicators. Can you outline for us some of the causes that contribute to this issue and talk about why these types of generalizations are harmful or damaging? Modern medicine, in particular modern epidemiology, is incredibly negative. So I'm going to kind of push back on some of the words in the depiction of Alaska Native American Indian people. Turns out that the vast majority of Alaska Native American Indian people lead pretty healthy, successful lives despite being in often very challenging circumstances and generational traumas and effects of death and colonization and so forth over the last 150 years. But despite that, the vast majority are quite successful, leading quite healthy, relatively healthy lives despite that. And yet modern epidemiology insists on cataloging people in entirely negative ways. How many of these bad things are happening? How many of these bad habits occur? How many of these bad choices are people making is what modern epidemiology is entirely built around. And a lot of my tribal leaders I look to for direction and learning on this topic are pretty upset about this. One in particular I hold in particularly high regard just hammers on this idea that she and her children and nieces and nephews hear nothing but negative things all the time, particularly from medical people and particularly from epidemiology people. And that starts to become deterministic and actually does harm. Thanks for that perspective, Dr. Eubies. It's really interesting the distinction you draw between what you mentioned and, as you say, modern epidemiology. I think that distinction is really important and probably not aware or visible to many in the health care field. Monica, at SCF, your work centers almost exclusively on the Alaska Native population. From your perspective, are there specific issues, health or otherwise, that are unique to Alaska Native people that influence your work? I'm going to piggyback on what Dr. Eubie mentioned. And so it's really focusing on the whole person's health journey while taking into consideration all of the traditional activities that we do. Our community is a resilient community that incorporates traditional practices to support their health care journey. Throughout the years, families are going out to do subsistence fishing, hunting, berry picking, boating, and more. It's kind of just our tradition as a family to go out and stay healthy but also be active. And taking those outdoor concepts into consideration and incorporating them into our health care journey by creating trust, buy-in from the families, and then interest from the community. Instead of having a provider come and tell you, I need you to eat healthy, eat all your vegetables, exercise three to four times a week, so really, really understanding the community that we're serving and what their interests are. We have a health education department on site that does, every Friday, cooking classes virtually where families are able to join. You got berries over the weekend. What do you want to cook with the berries? A lot of traditional meals and diets of really understanding what families are doing at that time and incorporating that into the health care journey. I just want to emphasize that we just focus on whole body, whole person, instead of just a single diagnosis. So it's a shared responsibility, that's why we call them customer owners. We trust the customer and then they're taking ownership of their health care, so I have my ownership of making sure that I'm eating healthy, staying healthy, incorporating all these traditional values as my primary care team is there to help support me in my health care journey. Thank you, Monica. Let's get a little bit deeper into some of the specifics around some of these issues. I'm just thinking, Monica and Dr. Eby, indigenous people, much like any cultural, ethnic, or spiritual group, have a set of values that govern how they operate in the world and what's important to them. Of course, these values differ greatly by tribal affiliation and location. I'm curious, for the communities you serve at SCF, what would you say some of those values are? Often, when people hear values, they think of sort of the intangible words, but I'd rather reframe it as assets and strengths and priorities for Alaska Native people. So for example, there's a great sense of expanded family and responsibility for expanded family of village identity and loyalty to people from a particular village, whether blood relatives or not. A sense of community responsibility and identity of the annual cycle of earth-based activities like fishing, hunting, berry picking, and everything that goes with these activities of welcoming each other into each other's lives in a fully embracing way. So this does get to some of those intangibles like generosity, embracing of each other, communicating, joking, laughing, teasing, respecting the natural flow of life and the environment in which people live. I recently just read an article that was a person visiting from the East Coast, non-Native person from the East Coast, visiting a fish camp. And a 10-year-old asked the person, where is your smokehouse and what is the name of your river? And to this person from the East Coast, these were strange questions. What do you mean? What is my smokehouse and what is my river? But to this 10-year-old, that's how life was framed. Life was framed by this place, these things, these rituals and cycles of life that absolutely everyone in their environment engaged in and gave meaning, purpose, and structure to how life is to be lived. I am a family physician by training, by the way. So if I'm seeing a 55-year-old Alaska Native man who's struggling with a new label called diabetes, if I lecture him about his hemoglobin A1C and his nutritional habits and how he needs to change everything about how he lives, I'm probably not going to be terribly effective. Maybe a little bit, maybe I'll scare him a little bit, but you can't feel, touch, or see diabetes in its early manifestations. If I instead talk to him about how he lives in a city and he's in his 50s and he has young grandchildren and it's important to him to teach hunting, fishing, berry picking, putting up the fish, and putting up the berries as extremely important things. He wants to share with his children and his grandchildren and be able to teach them these things and take them back to the village where they are based and do these things at certain times of the year. He's going to need good eyesight to see berries and to fillet the fish without cutting himself. He's going to need good fingertip sensation to handle the guns and the fishing poles and the knives. And he's going to need good sensation in his toes in order to walk in the glacial fed streams that are murky and you can't see the bottom or to walk across a tundra to pursue berries or hunting. So if I talk about preservation of toe tips, fingertips, and vision to do the things that are important to his identity and that he wants to teach his grandchildren to give them identity and see these as strengths and assets he brings to the table, now I've got his attention about things he desperately cares for. This conversation is fascinating to me because it really highlights the benefits of focusing on a fundamental human experience that's really part of health, really at the core. And it really makes you think about how much we as a society can learn from foregrounding some of that thinking instead of backgrounding it. Kind of similar to your comments, Dr. Eby, from before about our system has become so mechanized in a certain way, right? And we're—and simply by reframing some of these issues around what it's like to have a full human experience, there's a lot to learn from that. So I appreciate your reflections. We're going to shift the conversation just a little bit now toward designing for Indigenous populations specifically and some of the specific considerations from a process and outcomes perspective are important relative to the context that we've just sort of been talking about. Brian, I'll start with you. Can you explain a little bit about how a typical design process for a healthcare facility works and how that differs from an empathetic community-driven process that you advocate for? Yeah. So we've worked with the Alaska Native population for quite some time, dating all the way back to the early 1950s where, you know, we were tasked with designing their Alaska Native Medical Center Hospital. Since that project, there was a lot of effort put into the exploration and understanding of the Native culture and trying to really make sure that we weren't sort of coming in as outsiders to tell Natives this is how to deliver modern healthcare. But really, this was an approach to understand how Natives operated as a family and—or how care was delivered in a Native culture. With this came a lot of design explorations from, you know, visiting towns and visiting small neighborhoods and clinics to really start to get a sense of how we approach this design. And within that, what we learned is this sort of model of care needed to sort of accommodate large families. And so this gathering place that is at the heart of the Alaska Native Medical Center, when you arrive in the door, you know, you might sometimes be greeted by song and dance and stories where I think Natives come and share experiences and share stories in a much more, I think, intimate setting. And I think that's very different from, I would say, a lot of places that I've been working in. And I think this idea that is kind of intertwined into this sense of storytelling, you know, storytelling, they see it as like a resource, right? If we can think differently about how people share and sort of offer support, I think only then can we change, you know, maybe the mindset of how we can start to think of, you know, our own approach to healthcare. Moving forward to what we're doing today, currently working in Wasilla, and I think building upon some of those ideas of understanding is the NUCCA model of care that South Central has founded. It's this model of care that is really focused upon the, not necessarily patients, but what they call them are, you know, customer owners. It's basically putting the power back into the patients where they can now have a sense of ownership, their healthcare delivery system. And I think within this comes this sort of breaking the sort of barriers of a provider and sort of patient where, you know, there's a bigger sense of trust and a higher sense of sharing that happens. And so with that notion, I think we start to build upon, you know, this idea of really, you know, leaning into the way the Natives have a sense of pride and culture. But also how they sort of, you know, look at the world and the integration of how nature and their sustenance of living, you know, is intertwined. And so building upon that, we've created a concept or idea that is around light and how light starts to mark certain calendar dates that start to then indicate certain aspects of their living, whether it's berry picking or hunting or fishing. Some of these moments within their culture is then celebrated. And I think it brings a sense of understanding and ownership to a place. And I think it allows for better outcomes when we design for these people that have a very specific need and or sense of ownership. Monica, large family support groups are important in Alaska Native cultures. And many people in SCF's clinics and hospitals know each other and may be related or even from the same village. What are some solutions, both design and policy-related, that an organization could implement to accommodate this preference? For example, I know that at Alaska Native Medical Center, there is a hostel for family and a hotel and temporary housing owned by the medical center. Absolutely. Kind of design-wise, what we have here is talking rooms, family rooms. We have a case manager that is dedicated to each primary care team that really builds a relationship with a customer owner and that's helping them, supporting them through any kind of travel, lodging, needs that they need while they're here. We have a hotel that's on site or very near. We help coordinate travel and transportation needed for all the customer owners that are coming. There's a lot of travel that happens coming from some of the villages back. So just really supporting the whole healthcare journey and supporting the families as they go through this. Understanding family travels and family, extended families coming, so creating rooms that are adequate for those families. As for knowing, I feel like I am related to a lot of folks on campus working with them. We're a small community. It's that relationship and that trust. So since I've got my care here, I have the same case manager that picks up the phone every single time I call to make an appointment. Her name is KK. I'm able to call KK and tell her, hey, I need to get in today. I have this going on. And from there, she knows my story. She knows my family. She knows my history. She's able to talk with me about what we did over the weekend, but also get me my primary care team and get me an appointment. And so it's really that relationship-based care that we're providing. It's a small community. And then also taking into consideration a lot of the traditional aspects of care that we're providing. So understanding everything that goes into care is not just creating an appointment and getting the care for that family. It's really thinking about the whole journey of how do you get to campus, how do you get the care, what do we need to provide for those families. Thanks, Monica. It makes me think about your point about the relationships and how something, again, going back to the fundamental parts of a human experience, something as fundamental as great positive relationships can actually serve as a bit of an incentive for preventative care or just health care in general. And I think it's a good reminder to all of us that are in the health care industry that it is about relationships on a kind of fundamental human level. And some of those relationships actually can inspire one to be healthier and lead a healthier life. And I would add, you just reemphasized and confirmed the power of relationships, as Monica described. But the other thing she described was the immediacy of those relationships being available. And this is extremely important. In today's world, everyone, including almost all Alaska Native and American Indian people, have smartphones and live in an environment of immediacy. So we need to have those powerful trusting relationships. I'm not the case manager that knows Monica that Monica knows, but she and her family need access to that case manager directly, not through a phone bank, not through a front desk, a direct phone call, which is what she just said. So text, email, phone, video or in person for 23 years, we've guaranteed that to tens of thousands of people here. And 70 percent, pre-COVID, 70 percent of our touches on any given day were virtual. It's a complete reinvention of the philosophy, the words, the framing and the structure of the delivery system, which influences then how you build your environment. So for example, we eliminated nurses stations over 15 years ago. There's no private rooms or private offices with doors on them for anyone in our entire environment. Monica and I have laptops and spend our time in the programs we're supposed to be working with and have a little tiny desk somewhere we can perch if we need to once in a while. So everything about the physical environment needs to be rethought and redesigned. If you're going to have physical spaces that actually support this way of doing business, optimizing team communication, connectivity, not exam room centric. I'm here to tell you what you should do and then judge you when you don't do exactly what I say. Dr. Eby, you know, for Brian and I and our sort of part of the industry on the design side, I think we've definitely noticed return or maybe an enhanced prioritization of nature and access to nature, access to daylight. I think we all know that that really has positive health outcomes. But it might be, Brian, after the pandemic, there seems to be an even higher emphasis on nature and access to daylight and all the benefits that come with access to nature, especially in a health care environment. Dr. Eby, I'm just curious, from your perspective, indigenous populations often have a strong connection to nature as well. And patients and visitors may prefer nature and outdoor spaces to receive care, but also to socialize and connect, as you mentioned earlier. How does SCF incorporate nature into its design and patient care strategies? And how might other organizations do so? The short answer is that everything matters. And every single inch of every single space matters. And we design every one of our spaces, public, private, staff, everything. Every inch is designed to be exactly the way it is, because if you get your space wrong, you can't do your program right. But it's important to know who you are. We are in the city, and we therefore support all different tribal groups of Alaska. There are 229 tribes in Alaska. There are seven major language and culture groups, depending, again, how you define that. And they are very different from each other, very different. And so being in the city, we don't want one culture to feel like they're the hosts and everyone is the guest. We want it to feel comfortable and welcoming to everyone. And that this is their space, owned, managed, driven by them. And so we spend a ton of time being super intentional about textures and colors and inferred meaning. We spend about 20% more money on public spaces than the usual health care company does. Because gathering and sharing and being a community center is a huge part of our purpose that supports our mission. In our public spaces, we do things like with winter solstice and summer solstice using concentrated beams of sunlight and prisms and colors that are passively done in alignment with the sun. And we do a lot of things around texture and carvable, like yellow and red cedar that are carvable surfaces. And the idea is that the history and story of this people in this place becomes part of what the building expresses. Dr. Evey, I remember my first time visiting Alaska Native Medical Center and I was blown away. Entering the lobby was unlike any lobby of a hospital I've ever entered. It was families gathering and talking and sharing stories and a guy sitting in the corner playing music. Everyone's singing along. It was such a different experience from everything I've experienced in the States. Building onto that, from your perspective as a designer, as a health care architect and health care designer, for an organization embarking on designing a facility for a specific population, whether it's an indigenous population or another very specific population, what would you suggest as a first step or what things have you seen in your work in your past and present projects and your process that you think is maybe broadly applicable to health care design? You know, I think having worked in Alaska with native populations, one of the unique things that is interesting, especially with what South Central Foundation has been doing is following along the lines of the NUCCA model of care, you know, this idea of breaking down the barriers between providers and people that are receiving the care. I think the more connection we can bring there, the more personalized care that we can bring, they see storytelling as a resource. Can we change the way we think about delivering care in, you know, I'd say in majority of the U.S. in a sense that we can then offer a much more personalized care that gives power back to the people? So we'd like to spend the last few minutes of our episodes talking about the future. I'd like to ask each of you, what type of future do you envision or hope for when it comes to the next generation of indigenous populations and design and environments? Dr. Eby, I'll start with you. Well, we've spent 25 years trying to figure that out here and continually checking back and checking back and checking back. So we go to the community, we spend 10 times the usual amount of time, effort and energy on listening to the voice of the community and we never, ever stop. We say, you know, you said you want this, we try this, how's that working for you? And continually reinvent and reinvent and reinvent. Where we've ended up after 25 years of effort is to have a hub that's your hub for everything. So it's your hub for adults, for children, for elders, all ages, all genders. It's your hub for medical, behavioral and social. So primary care means to us, your trusted hub in relationship with you, when, where and how you want to connect to the people who know you for literally everything. And then we pull resources towards that hub. So the pediatricians are in that hub, the pain experts are in that hub, the addiction experts are in that hub, the child and adult complexity are in that hub, the elder geriatric experts are in that hub. Once you have this super powerful generalist hub capability for literally everything, you also have to build deeper dive capable things for big chunks of the population that we know exists. So children with special needs, we now run probably one of the world's best, most sophisticated neurodevelopmental clinics for children with lots of deep dive neurodevelopmental issues, autism, brain injury, fetal alcohol, all these kind of things. So we're doubling down on the deep things that create a fabric where self-determination and control of your own health journey become possible with our support. And just to reemphasize the facilities part, if you don't get the space right to support that, you will not get this product. Everyone involved needs to be sitting together in very intentionally designed spaces and everything about your spaces needs to message shared responsibility in a respectful way. Monica, how about you? What's exciting to you about the future of care for indigenous populations? I just have to say we've come so far. If we had the system that we have today, when my dad was going through his health care journey, he would be in a different place in his life. The next topic that I would love to see, and I think this is my most favorite piece of it, is we need to grow our community into these clinical roles, into these professional roles. So creating trainings like we have a RAISE internship for Alaska Native American Indian kids that are going through figuring out what they want to do in their life. We do certified medical assistant training and getting our community into these clinical roles. We have scholarships. We have so much. We have RN case manager internships. So creating that foundation for our community to provide care to our community is one of the biggest passions that I have and I want to see grow even more in our community. Our workforce population is more than 50 percent Alaska Native American Indian, and I just want to see that number grow in the future. Brian, what advice would you give to other designers in approaching projects for specific and special populations like the ones we discussed today? Yeah, my advice to organizations and teams, you know, looking to projects for specific populations, get an understanding of the place, diving as deep as you can into understanding the place, the culture, the stories. All these things start to form a unique perspective of design, a unique perspective of how we create meaningful and purposeful spaces. Thank you so much for joining us today. Special thanks to my guests, Dr. Doug Eby, Monica Lee and Brian Uyasugi. To see images of some of the projects discussed and for more information on the ideas discussed on today's episode, please visit our website at nbbj.com. If you like what you heard, please share, like or review wherever you get your podcasts. We'll see you on the next episode.