Northwest

For the second year in a row, the Northwest region experienced the fewest workplace injuries of any hospital-based region in Kaiser Permanente. The Northwest ended the 2011 reporting year with a 15 percent improvement over injury rates in 2010. (The two California regions, Hawaii and the Northwest operate hospitals, while Colorado, Georgia, the Mid-Atlantic States and Ohio do not.)

Workplace Safety Committee co-leads Marilyn Terhaar and Susan McGovern Kinard attribute the region’s success to several factors:

• Real-time information. Terhaar sends safety alert emails to managers, stewards, UBT co-leads and safety champions. The alerts list the injuries for the prior week and offer safety tips and resources.
• Goals at the frontline. Keeping injury rates low is a regional goal and a PSP goal. Unit-based teams are encouraged to work on these workplace safety issues prior to tackling other goals.
• Culture change. Safety conversations have become part of the workplace culture. If an employee sees someone not working safely or a hazard in the work area, she or he speaks up, knowing the problem will be addressed.
• Investigation. The approach to safety is proactive. The Employee Health and Safety department investigates the root cause of an accident and tries to make sure the accident does not happen again.

High cost to both employees and KP

Employee injuries are significant in several ways. An injured employee may lose pay and time at work, and a department may have to work short, which may impact patient care. And there’s a financial impact on the organization—which eventually could affect member premiums.

 “The cost to open a workers’ compensation claim is about $1,200 on average,” says Terhaar. “Once you start adding in medical and surgical costs, the expenses can soar.”

Indemnity claims—those claims that cover employees with more serious injuries that require a longer time off—average $21,000.

 “That’s one of the reasons we have such a laser focus on safe patient handling. The risk to the employee for injury is so great,” explains McGovern Kinard.

Prevention

The Northwest region employs a well-constructed safe patient handling program. New employees are trained on safe patient handling, and more than 1,000 employees were retrained in 2011. Hospital and clinic policies require staff to move patients using safe handling techniques and equipment.

 “We have mobile lifts and overhead lifts at Kaiser Sunnyside Medical Center and will have the same equipment at our new hospital opening next year,” says Paulette Hawkins, RN, a workplace safety consultant. “In addition, all medical and dental clinics have mobile lifts and receive annual hands-on refresher training on request.”

Members of the workplace safety committee aren’t resting on their laurels. This year, they plan to bring the focus of safety to the UBT level.

“Most teams can solve their own issues,” say McGovern Kinard. “There’s been an increase in awareness that’s been growing steadily over the last five years. Our numbers say it all.”

“This whole project was a mere idea written on a piece of paper only a few months ago,” says Juan Piantino, MD, “and now it’s a reality.”

Shortly after Dr. Piantino, a neurologist, came to Kaiser Permanente in July 2014, he was approached by another member of the department—Debbie Newcomb, an electro-neurodiagnostic technologist and UFCW Local 555 member. Newcomb’s work includes performing electroencephalograms (EEGs), a test that monitors a patient’s brain waves and helps diagnose patients with epilepsy.

She was interested in implementing ambulatory EEGs (AEEGs), an advanced technology that is relatively new. Because the test is conducted over a longer time period than a routine EEG, it is more likely to capture events that provide the medical team with information needed for a good diagnosis. AEEGs also are less expensive than an inpatient telemetry EEG. But Newcomb needed a physician partner to move forward.

“I wasn’t intimidated about approaching him,” says Newcomb, who’s the labor co-lead of the neurology UBT. “The partnership has given me the confidence to speak up—and in fact, I consider it part of my role as a union steward.”

Swift implementation

Dr. Piantino had experience with the test with other health care systems—as did Newcomb—and was enthusiastic. The pair began figuring out how the test could be implemented in the Northwest region. Newcomb collaborated with the staff at the Stanford Comprehensive Epilepsy Center to understand the specific details of its program. She worked with KP Purchasing to identify the type and cost of the machines that would be needed.

Armed with information, Dr. Piantino met with leadership of the Northwest Permanente Medical Group—and within a few short months, in December 2014, the region was equipped to do continuous ambulatory EEGs.

So far this year, 16 patients have had their treatment guided by the ambulatory EEG as outpatients. Because the test is administered with a camera, the physician reading the results can see the patient in real time and correlate the brain activity to the physical movements of the patient. In addition, being able to conduct the test in the patient’s own environment avoids a potentially stressful and expensive hospital stay.

One adult patient had been in and out of the Emergency department five times in two weeks. Newcomb performed the ambulatory EEG on him; he had five events, all pseudo-seizures. “He is now seeing the proper doctor for his problems—no more trips to the ED,” Newcomb says.

By the end of July, the program already had paid for the cost of equipment. The benefits of an accurate diagnosis for the patient are immeasurable.

“It was the positive attitude and the willingness to improve patient care that made this happen in record time,” says Dr. Piantino.

Kaiser Permanente is inviting patients and families into the boardroom to talk turkey. There’s no sugar-coating a bad experience or making excuses for less-than-stellar service. Listening to our patients has become a core value, and patient advisory councils are one of the ways KP is bringing the patient into the conversation to improve care.

“There are over 35 advisory councils and over 400 patient advisors throughout the organization,” says Hannah King, the director of service quality for unit-based teams.

In the Northwest, as in other regions, the work being done by the councils is affecting outcomes. Within six months of the formation of the Oncology Patient Advisory Council, for example, oncology patient satisfaction scores climbed 6.5 percent. One change prompted by patient feedback was a fresh look at a procedure that sometimes is used in the course of a surgical breast biopsy. After hearing from patients about the pain they were experiencing, physicians standardized the wire localization procedure to reduce pain.

One of the newest councils in the Northwest was created to help serve the region’s growing Hispanic population. Patients on the council have been involved in a video project that will be ready to share with staff by year-end. In the video, Latino patients talk directly to KP care teams about their culture, providing insights into how to build trust and develop good provider-patient relationships.

Patients who serve on the councils are not paid to participate. “These are people who are invested in helping us succeed,” says Jonathan Bullock, program manager for Patient and Family Centered Care Programs in the Northwest.

Given the complexity of an organization as big as Kaiser Permanente, there’s been a learning curve for patients as well. At a recent council meeting in the Northwest, patients expressed frustration that a suggestion to improve signage hadn’t happened. As it turned out, their idea had been incorporated into the master plan—but there’s a schedule for updating signage, and the clinic they were familiar with wasn’t due yet for a refresh.

The Transportation department in the Northwest is coming out of a tumultuous time. A lack of trust between managers and employees created a barrier that affected morale—and made it difficult to focus on improving routes and processes.

The department uses a robust but complex process for optimizing its routes. For maximum efficiency, it has to integrate a variety of work streams and figure out where there are redundancies that can be eliminated. Because of the complexity of the process, however, it had been more than 15 years since the criteria and requirements for the transportation system from the customer’s point of view had been reviewed.

Eventually, the UBT worked out a thorough route-modernization plan based on data-driven service requirements and metrics that established parameters on how to revise and design its routes.

But before it got there, it had to fix its communication, which broke down so badly the team entered into an issue resolution. In the Northwest, the LMP Education and Training department is responsible for facilitating issue resolutions.

Blame-free solutions

“There was a lot of tension in the department, and people were nervous about losing their jobs as a result of our work around revamping routes. Poor communication was a problem,” says Greg Hardy, sponsor and manager of the department.

The issue resolution process uses interest-based problem solving, and that helped the team focus on a common goal: Serving its customers was the top priority and improving communication was a necessity. From there, other agreements came more easily, and the department was able to maintain staffing levels and improve processes as a result of its efforts.

Improved communication improves service

As a result of the improved communication, the team was able to improve service levels and achieve the efficiency and cost savings it had strived for.

“We have a group of dedicated workers who want things done the right way,” says logistics supervisor Chris Dirksen, the team’s management co-lead.

When it came to improving communication, the team members’ first step was to get a baseline measurement of what they were trying to improve. They created a survey that would measure not only communication but also morale and UBT effectiveness. Once they had that information, they created a SMART goal: to improve employee perception of communication, morale and UBT effectiveness by 15 percent within three months, raising the overall survey score from 2.55 to 2.93 by February 2014.

As the team began to investigate the issues, it discovered email was not a good form of communication. Fewer than 20 percent of the team members knew how to log on and use Lotus Notes. The team brainstormed ways get employees to use Lotus Notes email and frontline staffers began to instruct and coach one another.

Three months later, the team sent the survey out again and found it had met its goal. Perception of communication improved 48 percent, morale improved by 56 percent and UBT effectiveness improved by 21 percent. The team scored 3.4 on its survey, exceeding its stretch goal of 2.93, and anecdotal reports are that the communication success is continuing now that the team has successfully completely the issue resolution.

New ways to communicate

Team members use several means now for communicating with one another, including email. A communication board has been set up in the department’s headquarters, near dispatch, that includes information about the projects the team is working on, notes from UBT meetings and a copy of the department’s weekly e-newsletter, “Heads Up.”

In addition, the team has gone from a representative UBT to a general membership UBT and now has regularly scheduled meetings throughout the region, so that all employees are able to participate. “This has been our biggest success to share information,” says UBT union co-lead Nickolas Platt, a courier driver and member of SEIU Local 49.

“It’s cool to watch from meeting to meeting how more people show up each time,” Hardy says. “The engagement of the team has increased as we began to see improvement, and people could see change.”

It started with a question from Oncology RN Tom Fought, a member of the Oregon Federation of Nurses and Health Professionals (OFNHP), at the Interstate Medical Office in the Northwest.

Why, he wondered, was primary tubing used for low-reaction drugs instead of the less-expensive short or secondary tubing?

That prompted the department’s unit-based team to start an improvement project that wound up saving $25,000 a year.

When patients come in for chemotherapy or other infusion medications, the drugs are administered via an IV: The bag holding the medication is hung on a pole, with a line that goes into the patient’s vein. When primary tubing is used, the valve to stop the flow of medication is very close to the patient’s body.

If the drugs being used have a high potential for an adverse reaction, it’s essential to use primary tubing, so that if there is an emergency and the line has to be shut, only a very little additional medication reaches the patient.

Appropriate times for less expensive options

When the short tubing or secondary tubing is used, the valve to stop the flow of medication is farther from the patient. In this situation, if the valve is closed, more medication is in the line and will flow into the patient until the tube is empty. These types of tubing are appropriate when the medication has a low potential for a negative reaction.

Primary tubing is $4.10 per unit, short tubing is $3.65 and secondary tubing is 65 cents. The costs add up if primary tubing is used when it’s not necessary.

“I had no idea that we would be saving the unit that much money by conforming the tubing,” Fought says.

This team alone was able to save $25,000 a year. If every Kaiser Permanente oncology infusion department adopted this practice, the savings would be dramatic.

“This was such an easy tweak—we just needed to think outside of the box,” says Lacey Anderson, RN, the Infusion Team Lead and a member of OFNHP, who was involved in the project. “The team realized this was such a great idea and wondered, ‘Why haven’t we been doing this all along?’”

Greater camaraderie

Heidi Rolf, the department manager and the UBT’s management co-lead, is proud of the work the team has accomplished. She attributes the success to the leadership of the team and notes that since the team has advanced to a Level 4 on the Path to Performance, team members have more camaraderie and are more engaged.

“At first it was a little difficult to change the habits of the nursing staff,” Fought says. “Within a few weeks, we had everyone on board and our tubing project took off.”

Tom Harburg, MD, is the physician in charge at Division Medical Office in the Northwest. He co-sponsors two primary care teams in the medical office along with the medical office manager and their labor partners. “Doctors can’t be cowboys anymore,” says Dr. Harburg, referring to physician Atul Gawande’s New Yorker article “Cowboys and Pit Crews.” Harburg agrees with Gawande that doctors need to work in a team environment and that, as Gawande wrote, “places that function most like a system are most successful…(where) diverse people actually work together to direct their specialized capabilities toward a common goal for patients.” Dr. Harburg talked with LMP communications consultant Jennifer Gladwell about being a sponsor and the value of having the physician involved in the team.

Q. What is your role as a sponsor?

A. As the medical director of the clinic, I work with the medical office manager and labor partners to help sponsor the teams. We help facilitate leadership. I think the strength of the unit-based teams lies with the grassroots approach. The ideas come from the front line. My role is to help build awareness and alignment to the goals of the organization and ensure that our approach is member-centric.

Q. What’s the biggest barrier you see?

A. The measurement is the biggest barrier. We have to be able to measure our performance to see if what we’re doing has any effect on our patients.

Q. How do huddles improve the work of the team?

The true benefit of the huddles is communication. There’s a social aspect to in-person huddles that allows you to address issues that pop up. It also facilitates learning and disseminating information—like the first day of a new protocol, you can remind folks at the huddles. I also think it’s a morale builder. Huddles foster good camaraderie. We only have two huddles per week at the clinic, but we have been doing huddles for three years. We’ve changed the time of the huddles based on the clinic hours, and now we’re going back to mornings.

What happens when things change in your job and you have to rethink what’s always worked in the past?

For me, that moment came two years ago when I moved into a management role. I had spent 24 years as a frontline nurse, union steward and labor partner to hospital administration before my job transition.

Frankly, I wasn’t sure what to expect going in, but having been a steward and a labor partner helped me become a better manager. Kaiser Permanente has given me opportunities to grow as a leader that I don’t believe I would have had elsewhere. Along the way I learned six lessons that I think can help others lead in a collaborative team environment:

• Speak well and connect. As a labor partner, I developed my speaking and presentation skills—skills that most don’t learn in nursing school. My confidence grew with each presentation and I now feel a connection with my colleagues that helps us all gain value from our conversations.
• Give and get respect. As a nurse, I was respected at the bedside by physicians, managers and other nurses. I don’t think I would have been as respected as a manager if I hadn’t been respected at the bedside first. My clinical experience helped give me credibility.
• Understand operations. As a labor partner I learned valuable lessons about hospital operations. That allowed me to build on my experience as a caregiver and begin to see the bigger picture—how things are intertwined and why certain decisions are made.
• Listen and hear. You have to be a great listener and actually hear what people are saying. You have to be able to take things in and think about how to respond. As a steward, I always mulled things over before reacting, and I try to do that still.
• Know your contract. Most union leaders know their contract inside out—certainly I did when I was president of the RN bargaining unit. Managers should, too. The National Agreement gives us many tools that can help both sides stay on track.
• Stay flexible, be practical. Nurses are very solution-oriented. The solution to a problem has to make sense. I learned over the years that different people might get to the same outcome, but there are many ways to approach the problem. You need to be willing to try a different route to get to the solution so that everyone feels they have a voice in the process.

As a labor leader, I learned to believe in people and know that there’s always another side to any story. My staff understands they can come to me any time. And our unit-based team helps us draw on everyone’s knowledge and allows everyone to be heard.

In the end, it wasn’t that hard to make the transition from labor leader to manager. In both roles you have to consider diverse points of view, and sometimes you have to step back and ask, “Does it make sense?” You’re not always popular, but I’m OK with that.

We may not always agree. But there is no “we” or “them,” we are all one—because we always put our patients first.