unit-based team

The Mammography Department at Sunnyside Medical Center was seeing about 370 patients per week, but 25-30 percent of those appointments were running behind schedule.

Appointments ran late because information was missing from the file, additional forms were needed or the wrong test had been ordered. This cost the technologist additional time tracking down information or following up on needed documentation during the patient’s appointment, which had a cascading effect.

The unit-based team (UBT) realized that many of the issues causing delays during appointments could be handled in advance of the patient's arrival. The team came up with the idea of setting time aside every afternoon for a technologist to review the following day's orders.

"Many times patients who are coming in for an appointment are here because something has shown up on a prior screening and their anxiety and stress levels are high,” Cheryl Maize, manager of Mammography, and UBT co-lead says. “By streamlining our appointments and ensuring appointments run on time, we are hoping to allay some of that stress."

Initially, a 3-4 p.m. window was set, but as staff began to test the new process, they learned that starting the work that late in the afternoon was not ideal.

In some cases, they needed to return phone calls or required additional information, and they couldn't get everything done by the end of the day. The team pushed up the pre-work orders to a 1-2 p.m. time slot and the results improved.

In addition, the team implemented a "double-check" system at 4 p.m., so orders were again reviewed to make sure any outstanding items had arrived and everything was ready for the patient's appointment the following day.

The technologist reviewing the orders also would leave notes in the file if there was something the technologist who was seeing the patient needed to know.

Patient experience improved with the new process. Appointments were on time, and technologists were better prepared to work with their patients because the orders had been reviewed in advance.

"The implementation of the screening of orders 24 hours prior to patient arrival has allowed us to maintain our allotted appointment times and has made it easier to accommodate surprises such as late arrivals and walk-ins," Laura Wellnitz, technologist, and UBT labor co-lead says.

Eventually, a technologist was checking orders and printing out appropriate paperwork for diagnostic mammograms one day in advance of the appointments. This eliminated 10-20 minutes per appointment. As a result, most diagnostic appointments were completed in the scheduled 30 minutes, so subsequent appointments started on time.

Other staffers also preferred the new process. They decided to take turns verifying and reviewing orders, which provided a welcome break in the daily routine.

When UBT co-leads at Sunnyside Medical Center took a closer look at their patient safety assistant usage, they agreed that reducing the number of hours was a top priority.

The patient safety assistants, also known as PSAs, were certified nursing assistants and provided a key service. They were assigned to sit in a room with a patient who had dementia, was confused or at risk of a fall. They could help if the patient tried to get out of bed, remove their IV lines, or became disoriented or restless.

And patients getting out of bed is not unusual.

Some try to get out of bed because they're bored and restless or they might need to use the bathroom. Restless patients often need a change of scenery, which might mean moving the patient to the nurses' station or to a public area. There might be a need to reduce noise by closing doors at shift change to keep it quiet.

During a five-month stretch, the Sunnyside nursing unit had used 1,550 hours on PSAs. At a cost of $62,000, they wanted to bring those hours down without adversely impacting patient care.

So staff members made it a priority to talk with the patients and families to learn about the patient's interests and hobbies and offer specific activities for patients to do during their stay.

"Using the activity boxes (which contain games, crafts, videos and more) with patients has been a great way to help patients stay busy, and it makes them feel better," according to UBT labor co-chair Glenda Vosberg, RN.

The goal was to reduce PSA usage by 10 percent in four months. Knowing this was going to be a full-team effort, a mandatory in-service was scheduled and the co-leads explained the situation to the rest of the team.

They trained staff on the options to using PSAs. They provided the team with baseline data and information on the financial impact of using PSAs, and had nurses assess patients to determine whether a PSA is needed.

The results were immediate.

In a month, hours dropped from 549 to 32 without any negative impact on patient safety. Within another two months, PSA usage fell to eight hours.

"Staff were given the data and information to help them understand the impact of the situation and get their feedback on alternative options to using a PSA," says Imelda Zapata, department manager and management co-lead.

The team also enlisted the assistance of Susan Woods, the clinical nurse consultant in the hospital.

One of Woods' responsibilities was to provide consultations with patients who were assigned PSAs. She worked with the patient, family and nurse to develop a plan that best fit the needs of the patient.

Kaiser Permanente also invested in several different equipment options, including low beds, which can be put all the way down to the floor, and bed and chair alarms that let nurses know if a patient tries to get up.

The combination of equipment, changes to the environment, and activities for patients allowed the team to keep their patients safe and improve their morale while decreasing the usage of PSAs.

"Often staff is concerned about patient safety when we talk about alternatives to assigning PSAs and may be reluctant to try other options. However, literature (and our local experience) shows that having a PSA in the room does not guarantee the patient won't fall or pull out their IV lines," Woods says. "We've found that reduction of PSA usage has not negatively impacted patient safety, just as the literature suggests."

Colorado’s asthma care coordinators discovered that children were refilling their medications at the lowest rate in the region. The group works alongside physicians and staff to provide education and outreach to Kaiser Permanente members with asthma or chronic obstructive pulmonary disease.

Inhaled corticosteroids help control asthma by reducing inflammation and mucus production. Asthmatics who use the meds daily experience fewer attacks, use their emergency medicine less and make fewer visits to the emergency room.

There are some common threads among patients, who don’t refill their prescriptions. These include the costliness of inhalers, the fact some patients are reluctant to take a steroid, and often patients stop medication when they start to feel better.

“It took us a while to identify the most important thing our UBT could do,” said Cindy Lamb, RN, an asthma care coordinator and member of UFCW Local 7. “It was definitely a learning process.”

So, the asthma coordinators decided to improve the refill rate through an outreach program and targeted members ages 5-17. They made phone calls to five members a week who had not refilled their prescriptions in more than four months. As part of the discussion they included talking points about the benefits of inhaled corticosteroids. They used trackers and scoreboards to monitor the outreach and keep everyone informed.

The seven asthma care coordinators were spread throughout the region, so they held weekly phone huddles to share progress and best practices. They highlighted the convenience of the mail order pharmacy, and provided members with prescription refill numbers as well as the telephone number to the pharmacy. This information helped patients refill their medications more promptly.

The team also had communicated regularly with pediatric physicians and other staff by phone, conversations, meetings, and email.

None of it happened overnight, but the team discovered the collaborative effort really helped the process. In all, they reached 1,100 patients.

“Give the process the time it needs,” said Asthma Care Coordination manager Leah Brines. “Resist the temptation to come up with solutions for the team and instead, guide the conversation, and encourage participation and discovery. The team, given the time and confidence, will find the solution.”