Spring 2014

Colorado

The new Lone Tree Specialty Care Medical Office, a 25-acre campus, boasts outdoor patios, picturesque mountain views and a walkway around the perimeter of the building. The facility, which opened in December 2013, was awarded a LEED (Leadership in Energy and Environmental Design) Silver certification by the United States Green Building Council. Lone Tree, which is near a light rail line, used recycled materials, water-wise fixtures and shading devices for balancing solar heat to win the LEED designation. The facility has nearly 350 employees and 45 physicians to take care of the 3,000 ambulatory surgeries and 3,000 minor procedures expected per year.

Georgia

What happens when two nurses from two different high-performing UBTs transfer to the same brand-new Level 1 team? That team zooms to a Level 4 in only 10 months. Jane Baxter and Ingrid Baillie, both RNs, had been UBT co-leads at the Crescent and Cumberland medical centers, respectively, and then joined the Ob/Gyn staff at Alpharetta. Drawing on their experience—at different times, they each have been UFCW Local 1996 members and members of management—they helped their new UBT move up through the Path to Performance. “We knew the steps in the process and what to expect,” says Baxter. Their advice to fledging teams: Start with small performance improvement projects in areas that clearly are Kaiser Permanente priorities and that already have lots of data collected.

Hawaii

Nurses on the 1-West Medical-Surgical unit-based team at Moanalua Medical Center vastly improved how well they educate patients about medications, moving from about 40 percent of surveyed patients saying they understood side effects and other aspects of their prescriptions to 96 percent reporting this awareness. Between April and December 2013, the RNs, who are members of the Hawaii Nurses’ Association (HNA), made notations on patient room whiteboards, rounded hourly and did daily teach-backs on every shift. The team members designed a three-day survey for a sampling of patients to report what they understood about side effects of their medicine. The survey provided speedier feedback than waiting more than three months for HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores.

Mid-Atlantic States

A Nephrology team at Tysons Corner Medical Center in Virginia helped patients prevent or manage chronic kidney disease by getting them into the classroom. Just 70 percent of the unit’s patients at risk of renal failure were enrolling in KP disease management classes in February 2013. But several successful tests of change boosted at-risk patient enrollment in March to 100 percent, where it has remained since. The team noted on individual patient charts if the member suffered chronic kidney disease, developed scripting for in-person coaching, mailed class invitations to patients’ homes and handed out class agendas with after-visit summaries.

Northern California

The Modesto Pediatrics UBT improved wait times for immunizations—and not only increased service scores but also reduced overtime costs, an example of how a change can affect an entire system. The team reduced patient waits for immunizations from 45 minutes to 15 minutes between June and August 2013 and maintained the improvement through the rest of the year. A workflow change was key to the dramatic reduction. When a patient is ready for an injection, physicians now copy the orders to a nursing in-box instead of searching for a licensed vocational nurse to give the shot. The half-hour reduction in wait times—which is credited with improving service scores from 86 percent to 95 percent—also reduced the need for LVN overtime by an hour a day, resulting in savings of more than $16,600 over six months. 

Northwest

The regional Employee Health and Safety department won KP’s “Engaging the Frontline” National Workplace Safety Award. Through the Northwest’s Safety Committee Challenge, facilities had to complete a rigorous set of tasks, including regularly scheduled safety meetings, joint planning with NW Permanente and Permanente Dental Associates, safety conversation training, awareness plans and a safety promotion event during the year. Of the 16 facilities that rose to the challenge, nine met all of the qualifications. The region ended the year with a 4 percent reduction in accepted claims compared with 2013. Leonard Hayes, regional EVS manager, won the individual award for his work, which contributed to the East service area’s EVS team going injury-free for the last four years.

Southern California

The regional LMP council has set a 2014 Performance Sharing Program (PSP) goal to power up unit-based teams’ achievements on improving affordability. When at least 50 percent of a medical center’s UBTs complete a project that saves money or improves revenue capture—and if the region meets its financial goals—eligible employees and managers there will get a boost in their bonus. “Imagine how powerful it will be to have a majority of unit-based teams achieving measurable cost-savings and revenue-capture improvements,” says Josh Rutkoff, a national coordinator for the Coalition of Kaiser Permanente Unions. “The idea is to take all the strong work on affordability at the front line to a whole new level.”

Take, if you will, the humble cell phone.

Oh wait. The cell phone may be ubiquitous, but it’s far from humble. Today’s smarty-pants phones have more power than the computers on the Voyager 1, which was launched in 1977 and 36 years later departed our solar system. Its three computers can process about 8,000 instructions per second. A smartphone swallows more than 14 billion.

The articles in this issue of Hank—articles about how technology is transforming care delivery and about how individuals and Kaiser Permanente are meeting the challenges that presents—would have overwhelmed the Voyager computers’ memory.

For communicating across distances, the string with two tin cans is humble. Even the rotary phone, patented in 1892, seems modest in comparison with today’s devices, which are used more for all manner of modern information sharing than for something as quaint as talking to another human being.

A rapid tech-based transformation, akin to the makeover of the old-fashioned phone, is already sweeping through care delivery. It’s hard to fathom the many ways technology will allow us to decentralize the delivery of health care while improving our connection with our patients and members. The changes will require new skills.

And starting today, the mindset we bring to the workplace is just as important as our skills. Without a willingness to explore new ways of doing our work, we are (to mix a metaphor) like an ostrich dialing the operator for help on a rotary phone, patiently waiting the long seconds for the 0 to return to its starting place while the future creeps up from behind. We’ll never know what got us.

Be bold. Be willing to go where no one has gone before.

See your doctor without leaving home? The house call of the future may be via your smartphone.

A visiting home health care nurse may one day live-stream exam information via a wearable device like Google Glass, speeding up the treatment process.

Or maybe you’ll be dropping in for a check-up at the clinic in your local shopping mall.

No one can say for sure which ideas will take hold, how long before those ideas morph again and how jobs will be affected. The good news is, we’ve successfully managed widescale change before.

“Changes in health care mean there will be job losses and job growth,” says Jessica Butz, the Coalition of Kaiser Permanente Unions’ national program coordinator for Workforce Planning and Development. “But in the long run, the new skills needed are good for workers and for our patients and members. We have options and support to make the transition work for us, and we’ll have better, more secure jobs.”

Joyce Lee, a Steelworkers Local 7600 member and a former imaging transcriptionist at Fontana Medical Center in Southern California, can speak to the truth of that. Four years ago, a new voice-to-text technology made her job obsolete. She now works as a phlebotomist, a job she always wanted.

“One of the things I’ve always loved about Kaiser is that you can have many careers here, you can be as good as you can be,” Lee says. “I got great support from my union, my manager and my career counselor.”

In the mid-2000s, thousands of workers across the organization saw their work vanishing as KP HealthConnect® was introduced. Time and again, Labor Management Partnership resources and safeguards not only kept individuals employed, but led to new skills and jobs within Kaiser Permanente that paid as well or better.

As KP implements new care delivery models, having a workforce planning and development program that draws on the input and experience of the workforce will help ensure smoother transitions and keep costs down.

“We want individual workers, teams and the whole organization not merely to survive change, but to thrive on change. We used partnership to do just that with HealthConnect,” says Hal Ruddick, executive director of the union coalition. “We don’t need to reinvent the wheel—we just need to get rolling on joint planning and implementation.”

Early engagement required

What all the new care models will look like is still taking shape. Despite the uncertainties, leaders recognize the need to start thinking now about how changing technology will affect the workforce. It’s becoming clear people will need to be trained for team-based care, to work seamlessly across different care settings and be technologically skilled or able to learn those skills.

“We have an opportunity—both labor and management—to lead on the new care models and to get ahead of those changes and get it right,” says Zeth Ajemian, the director of Workforce Planning and Development for Southern California and Hawaii. “It requires early engagement and flexibility.”

Remembering what we’ve already learned will help. The implementation of both KP HealthConnect and the coding process known as ICD-10 provides valuable case studies.

In 2009, the U.S. Department of Health and Human Services announced a big change for health care providers: The International Classification of Diseases, 9th Edition, known as ICD-9, would be replaced by ICD-10, which contains about 144,000 diagnosis and procedure codes. The changeover, now scheduled for Oct. 1, has meant 166 applications—including billing and claims systems in each region—needed to be upgraded, replaced or retired.

In addition, some 1,400 coders and many others needed retraining. Union coalition members are covered by the Employment and Income Security Agreement, which provides for retraining, redeployment and at least one year’s protection from layoffs due to process improvements or restructuring.

“Our ability to work collaboratively in partnership—and recognize workforce issues as part of our strategy—is huge,” says Laura Long, the director of National Workforce Planning and Development. “We need to look at the impacts on the workforce and the skills sets needed for the future. We can’t just flip a switch.”

Identifying potential problems

So KP and the coalition took a page from the KP HealthConnect playbook, when Kaiser Permanente leadership reached out to the unions.

“We had conversations about why the change was important and what it would look like,” says Marie Hamilton, RN, who was the national labor coordinator for KP HealthConnect implementation and is now the labor partner for OFNHP at Westside Medical Center in the Northwest. “Part of the implementation was making sure people got the skills they needed.”

The process was not pain-free, but by engaging the workforce, she says, “Kaiser got buy-in from the people using the system and identified potential problems early on. It was the most impressive thing I’ve seen in 40 years at Kaiser—a model that demonstrates how working in partnership can effectively manage sustainable change.”

When that engagement is missing, the repercussions can be far-reaching. Last year, for example, a decision to reduce or redeploy nurses in Southern California led to a pull-back in union support for unit-based teams in the region. The dispute was resolved, but it illustrated the risk of going it alone.

“In times of change, it can be tempting for both sides to fall back on old habits and traditional approaches—and we know where that gets you,” says Dennis Dabney, the senior vice president of National Labor Relations and Office of Labor Management Partnership. “The test of any partnership is working your way through tough issues and getting better results. That's what we are committed to do."

The joint approach to ICD-10 has included national “communities of practice”—with representation from frontline workers—to design training and make policy and budgeting decisions. Regular updates keep affected employees informed and let them air concerns.

One very specific payoff to the approach: The labor-management team in Colorado found serious flaws in a claims and billing system being developed by outside vendors. KP switched vendors and avoided a potentially disastrous disruption.

The Imagining Care Anywhere exhibit, created by Kaiser Permanente’s Innovation and Advanced Technology team and the Garfield Innovation Center, illustrates how current and emerging technology makes it possible to bring health care directly to a patient’s home—or wherever a member may be—and can transform the way care is delivered at the doctor’s office and in the hospital. Dan Weberg is director of nursing innovation at the Garfield center and has been traveling to Kaiser Permanente facilities, conferences and union meetings to talk with people at all levels of the organization about the exhibit. He was interviewed by LMP Communications Director Andrea Buffa.

Q. As director of nursing innovation, what kind of work do you do?

A. I have a really great job. I’m supposed to help envision the future about three to five years from now and figure out what technologies, what trends, what changes in nursing practices and what changes in health care might occur. And then help guide pilot projects and strategy and brainstorming sessions to move the organization toward that future.

Q. What is the Imagining Care Anywhere exhibit about?

A. Imagining Care Anywhere is the start of a conversation with everyone at Kaiser Permanente to create a vision of what it might look like in the future as we engage members no matter where they are. How can we seamlessly integrate their home life, their school life, their work life and their health interactions with Kaiser all together? How can we help people have a more healthy lifestyle or healthy work-life balance? It’s a tour that’s supposed to provoke people to think about and imagine what that care will look like.

Q. How are emerging technologies changing the future of health care?

A. One example is the smartphone. Many of us use it for everything from tracking our fitness goals to shopping lists to emails to Facebook. But the data and the information behind that can be integrated in with goals for your health life. We’re working on a project now called Profile and Preferences. You might be able to set personal health goals and then use the data you collect already—whether it’s through a fitness app or diet tracking—and upload that into your kp.org profile so you can see how you’re moving along with your goals. And then, when you meet with your care team, we have a better picture of who you are as a person, and we can help you facilitate your goals. Remote diagnostics and remote monitoring are a big deal now, too.

Q. What do you think virtual visits will look like?

A. There are several organizations now that do tele-visits, including Kaiser. I think the future is going to hold more of these as our TVs and our cable providers get faster and faster internet and smarter devices. It may not be a full visit, but it may be a way to engage with a care provider—whether it’s a nurse, a physician, some sort of navigator or a health coach. Keeping people from having to drive into one of our facilities for simple things is going to be key.

Q. How are things going to be different when people are in the hospital?

A. In the exhibit, there’s a “journey home” board, which allows members to know exactly what has to happen before they get discharged. They don’t have to continue asking the nurse or the doctor or the care team by clicking the call light—they can see it right there and they’re able to access it.

The board is also about answering their questions conveniently and in a way they can understand. The exhibit has the idea of using an avatar. After a nurse or teacher comes in to do some kind of education, the member still has some questions. Instead of having to ask the same questions over and over and feeling a little uncomfortable, they’re able to use a virtual person to answer them.

Q. How can KP support its employees and help them advance their careers as these changes begin to take place?

A. I think as an institution we need to keep thinking about how we evolve our roles, what are the things we need to do differently. The technology is coming whether we want it or not, so it’s about continuing to imagine how specific roles might change and coming up with strategies to train our workforce to be able to evolve with the technology.

Q. What role are the labor unions that represent KP’s employees playing?

A. We’re really excited about the engagement with the unions. I think it’s great that they’re using Imagining Care Anywhere as a springboard to talk to their constituents about how the future of health care is going to evolve and also work to create that future with us.

The front line should be driving this because they know what’s broken. And they can help us address that early, before we get too far down the road with a solution that may not meet the real need.

A January UNAC/UHCP steward meeting in Southern California included a traveling version of the Imagining Care Anywhere exhibit, and nurses across Southern California weighed in with their thoughts about the emerging technologies.

Gracie Johnstone, RN
Kern County

Our dermatologist left and we didn’t have one for a while. We did “tele-derm” with a doctor in Orange County. We trained the medical office assistants on how to set up the technology. We could do the biopsies, if needed, at Kern. It evolved really nicely. It saves a visit for the patient. I don’t think all this technology will take jobs from nurses because we still need the human touch. Nurses will become more techno-savvy.

Pam Brodersen, NP
Downey Medical Center

It’s great, but we have to slow down a bit. We don’t want to become an app. We still need that human connection.

Yoshini Perera, RN
Downey Medical Center

I love change, but I’m a little concerned we might get out of touch with the patient. As long as we can listen to and touch and feel the patient, that’s OK.

Nelly Garcia, RN
Panorama City Medical Center

I am concerned about the ability of computer systems to communicate with each other. We need to get the systems to connect in order to provide the best service.

Gerard Corros, RN
Irvine Medical Center

It’s like having a Ferrari all of a sudden. You can drive really fast, but you need speed limits.

Marcella Austin spent her first six years at Kaiser Permanente as a medical assistant. Three years ago, she became a licensed vocational nurse through a partnership between KP, the Ben Hudnall Memorial Trust, Chaffey College and the San Bernardino County Workforce Investment Board that funded a Pathway to LVN project. That gave her the support she needed to advance her career—tuition, books, tutoring and wages. She was one of the first of nearly 50 KP employees to graduate. She was interviewed by LMP Senior Communications Consultant Anjetta McQueen.

Q. What started you on your journey?

A. My father, who is diabetic, had a heart attack when I was in college. My mom and I were the first ones at the ER with him. It was scary, but I remember those nurses and how they took care of him and us. One of the nurses took an orange from her lunch and taught me how to do an insulin injection. I fell in love with nursing. Six months later, I became a medical assistant. I thought that was as close as I would get.

Q. How did you manage school after years of working?

A. I went to school full time and worked in Urgent Care from 5 to 9, getting my 20 hours a week. The Ben Hudnall trust covered the other 20 hours. I never lost a paycheck. It’s not like I could say I didn’t have the funds—the funds were there.

Q. What about the responsibilities at home?

A. I have two kids, a 16-year-old daughter and a son who is 13. I had a husband, mother and mother-in-law all helping me out. I used to be the one who cooked, cleaned and picked up after everyone. All of this helped my kids become more responsible.

Q. College nursing slots are hard to come by. How did Chaffey College help?

A. I have taken one course or another since graduation from high school. I also took time to get married, have children. Chaffey pulled all of my transcripts from everywhere and offered the prerequisite classes I still needed.

Q. Your wages and tuition were covered, but how did you manage all those other costs?

A. We owe a lot of thanks to the county’s Workforce Investment Board. They saw a need for educating people in the community. We didn’t have to worry about transportation, uniforms or supplies during our clinicals. All of that can really add up.

Q. How did the cooperation of your labor management partners help you?

A. Managers and labor leads stayed with us every step of the way. They had meetings with us. They kept asking us how they could help. If there was a barrier, if a schedule needed changing, they would work together to see that it got done. I especially appreciate the help from Susan Rainey, the department administrator for staffing at Ontario; career counselor Michele DeRosa with the Hudnall trust; Margaret Winningham, a senior Human Resources consultant for Fontana/Ontario; and Valerie Robinson, a Local 7600 representative.

Q. What is different about your work now?

A. In the LVN training, you get the basics—biology, anatomy, psychology—but you also learn about nursing care plans, sterile processing, wound care and get hands-on training all while attending school. I can assist RNs in several procedures, do minor surgical assists, order and co-sign documents in KP HealthConnect®.

Q. What is different about you?

A. My confidence has gone through the roof. I was selected to go to the KP Quality Conference, and I was invited to speak in a leadership meeting about my experience. The girls on the unit tease me now, saying they want my autograph.