Colorado

The Molecular and Cytology Lab unit-based teams in Stapleton, Colorado, were facing a challenging trifecta. Increased membership, changes in guidelines from the Centers for Disease Control and Prevention (CDC) and slow work processes made it tough to quickly process two widely used tests.

Membership in the Colorado region has grown by more than 60,000 members since 2013 in part because of the Affordable Care Act. Total membership in the region is now at its highest ever, with more than 600,000 members. The influx of new members is a strain on the system, and teams are digging in deeply to meet those members’ needs, from the first point of contact in the medical office to the last encounter as they pick up their prescriptions on the way out.

The lab teams are feeling the pressure, too—especially since they also process samples for the Georgia region, which is expected to grow, and they still do some work for facilities in the former Ohio region, which was sold to another health plan last year.

“We knew there would be an increase in the number of tests we would be doing. We also knew that our process was very labor intensive,” says Roxanne Whitesides, the Molecular and Specialty Testing manager. “Already this year, we’ve increased our workload 10 percent because of an increase in membership.”

Preventive care approach

The screens in question are for the human papillomavirus (HPV) and the Papanicolaou (Pap) test. Both detect disease at an early stage when treatment is highly effective, and so are central to Kaiser Permanente’s preventive care approach. As of June this year, the Molecular and Cytology teams—each of which has a role in processing the screens—already had processed 23,300 Pap screens and 16,800 HPV screens.

Meanwhile, CDC guidelines on HPV were revised in recent years and now recommend that women age 30 to 64 have an HPV screening and that girls as young as 11 receive the vaccine. The agency says HPV is the most common sexually transmitted infection in the United States. Some strains can cause cancer, and the CDC says about 21,000 of the HPV-related cancers each year could be prevented by the vaccine.

Because of the changed recommendations, even before the enrollment jump, the labs were seeing an increase in the number of HPV screens they processed. In 2012, the labs processed 650 HPV screens a month. By this spring, the monthly average had more than quadrupled: the average for March, April and May 2014 was 2,800 per month. In May alone, 3,354 samples were processed.

Labor-intensive processes

The final hurdle the teams faced was that their processes were labor intensive, requiring significant hands-on time from the technician. There was frequent back and forth between the Cytology and Molecular departments, which caused delays and interruptions. The complex work processes added to the pressure of the growing workload and caused frustration and tension.

The teams began an intensive study of what other labs were doing, including researching the latest technology. They visited other sites and vendors and decided to go with a cutting-edge Roche instrument. The pathologists—who work closely with the labs—supported getting the new equipment, and the lease was fast-tracked for installation. The instrument was in place within two months.

At that point, the teams set to work to figure out how their processes would change with the new equipment.

Cross-training provides insights

“We trained each other on the new equipment and on the processes within the two departments,” said Luann Martin, a cytology technologist, UFCW Local 7 member and co-lead of the Cytology unit-based team. “I could appreciate things going on in both departments.”

The collaboration between the Molecular and Cytology departments enabled them to improve their work processes and interactions—and ensured that as one problem was fixed, another wasn’t created.

“It’s important to keep talking. People have different expectations and comfort levels,” says Beth Fisher, a medical technologist, UFCW Local 7 member and co-lead of the Molecular UBT. “Be patient with one another,” says Melissa Baca, a cytologist lab assistant, SEIU Local 105 member and union co-lead of the Cytology UBT.

Most important, Fisher says, the new equipment is enabling the teams to meet the growing demand.

“The big payoff is that we're able to process all those HPV samples in less than half the time it used to take, so we've been able to absorb the workload increase with no new staff,” she says. “And we're able to identify the HPV strains that are most linked with cervical cancer as part of the initial screening. That saves money, because we don't have to send out all the positives for additional testing.”

It’s not every day you hear of physicians offering to step in and help out staff in their assigned duties, but at the Primary Care department at Englewood Medical Office in Colorado, that’s exactly what happened.

The nursing staff, short-staffed due to medical leaves, “was overwhelmed,” says Kate Frueh, DO. Messages from patients were piling up in the electronic inbox in KP HealthConnect. Patients who might have been helped by phone or via email were coming in for appointments—making it hard for those who truly needed the in-person appointments to be seen.

“We think we’ve got some of the best nurses in the region,” says Larry Roth, MD. “We just thought, how can we help the nurses and, at the same time, help both ourselves and the patients?”

Physicians dive in

So the team brainstormed ideas, and the physicians offered to help clear the backlog.

“The nursing staff was flabbergasted,” says Linda Sawyer, RN, a member of UFCW Local 7 and the department’s labor co-lead. 

After testing a couple of time blocks and working together, the physicians began setting aside 30 minutes every morning to help triage messages and call patients back directly without getting the nurses involved—and they do it again in the afternoon.

As a result, the team consistently closes encounters within an hour more than 40 percent of the time. With more problems being resolved by phone, appointment slots have opened up and access for patients needing in-person appointments has improved. Morale in the department has improved, too—and the team recently won the Colorado region’s quarterly “Value Compass” award.

Meantime, team members have been working with Linda Focht, their UBT consultant, to boost their Path to Performance ranking—which was only at Level 2 late in 2012, despite functioning at a high level in most dimensions of the Path to Performance.

Common challenges

Focht says some of the challenges that held the team back are common across the program—a department reorganization (including a reduction in staff), new work procedures and gaps in team training. And there were new co-leads who were unfamiliar with the process for assessing team performance.

With some of those issues addressed in the first months of 2013, the team moved up to a Level 3 in the most recent ranking.

“The team members kept their focus on the goal of more streamlined work processes,” says manager Mary Watkins, RN, “and all of the staff of the Primary Care Department are helping each other to become more successful.”

 Watch a video about this team on the KP intranet.

Colorado’s “small team with the big impact” has surpassed even its own expectations, reporting an additional $7 million in Medicare reimbursements last year. That brings the total capture to $10.3 million for Medicare Advantage visits in 2010.

The Medicare Risk Business Services unit—made up of five auditors, a data analyst and a manager—is in charge of auditing all inpatient Medicare Advantage charts to make sure the agency is billed correctly.

Two years ago, a technical issue with Kaiser Permanente’s partner hospitals in the region resulted in incomplete physician signatures on patient charts—which prevented KP from submitting the bills for hospital stays and procedures to Medicare for reimbursement. The error was corrected, but the team had to review 26,000 hospital inpatient notes for that year.

When it first began correcting the error, the unit-based team predicted collecting an additional $2 million to $3 million for 2010 and team members are pleased that their efforts netted KP an additional $7 million.

“It amazes me what the UBT is able to harness and have such great outcomes,” says management co-lead Treska Francis.

The department has worked through the backlog and is now able to submit bills to Medicare within 10 days of a patient’s discharge.

The small team attributes its ongoing success to:

• quick huddles
• holding each other accountable
• transparent communication

“On a daily basis, we know what needs to be completed for the day, (we) set a goal and we go for it,” says labor co-lead Stephanie White, a Medicare risk auditor and SEIU Local 105 member.