Mid-Atlantic States

The dread is familiar: You have a question or a problem, and you need to call a service center to get the matter cleared up. Will the issue be fixed quickly? Or will the call be transferred from one person to the next—to the next—to the next?

As the second open enrollment period under the Affordable Care Act approached, Kaiser Permanente’s Customer & Member Services team knew that it didn’t want the thousands of new members joining KP to have that sort of frustrating experience. Just the year before, C&MS’ Member Service Contact Centers (MSCC) had been swamped by three times as many calls as expected. That had led to many handoffs to Membership Administration, which works with the MSCC customer service representatives to get questions answered. 

And so the first-ever “super unit-based team” sprang into action in September 2014. Its mission: To combat long wait times and better handle the anticipated surge in calls that would come with open enrollment.

What made it “super” was that it transcended locations and time zones, bringing together on a single team representatives from across the country—from the MSCCs in Denver, Colorado; Fulton, Maryland; and Corona, California, and from Membership Administration in Denver and San Diego. In the past, an individual UBT at one of the centers might develop a good practice, but it was left largely to chance that other centers would learn of it and follow suit. But under the umbrella of the Open Enrollment 2015 Readiness Initiative, 29 frontline and managers, supported by regional and national leaders, took a fresh approach to testing initiatives and spreading best practices.

Unifying approach

The combined team helps everyone operate as one team instead of separate entities, says Deashimikia Williams, a customer service representative at MSCC-Fulton and an OPEIU Local 2 member.

The collaborative effort was important because members don’t distinguish between different centers or different divisions. “They see us as One KP,” says Marie Monrad, vice president of strategy and operations for the Office of Labor Management Partnership, “and with this, we are doing performance improvement as One KP.”

The Super UBT’s biggest success so far is known as “one and done”—meaning that the member’s question is taken care of by the representative who picks up the phone. Before, a member’s request to stop an online payment, for example, might have taken up to a half-dozen calls. But with the introduction of the one and done process, the MSCCs were able to reduce the number of handoffs by 60 percent from January 2014 to January 2015.

The secret to success was looking to the customer service representatives for answers, says Jerry Coy, senior vice president of Customer & Member Services. “We asked the people who actually take the calls, ‘What questions are members asking?’ and ‘What would make your job easier?’” he says. “We are the front door to KP. We welcome the members and want them to be a member for life.”

“All of this work is in line with the Labor Management Partnership’s commitment to grow and maintain membership for KP,” notes Janelle Williams, consultant specialist for frontline engagement and growth. 

Answering calls from all over

The call centers that participate in the Super UBT answer the majority of KP member calls from the entire organization, fielding questions on a range of topics from billing to details of the health plan to helping members who haven’t received their membership cards.

Super UBT members received additional education and created a rapid resolution team within Membership Administration. While the representative stays on the phone with the member, he or she can consult with specialists via Lotus Notes SameTime chats or by opening another line. From mid-January through early March, the MSCCS handled nearly 5,400 calls—and more than 5,000 of them were successful rapid resolution calls, with the members helped in a single interaction. In addition, through staffing changes, operational improvements, and the implementation of the rapid resolution team, Membership Administration has reduced mean processing time for member issues from 26 days in January 2014 to three days in January 2015.

While Kaiser Permanente members benefit from the work, the frontline staff members benefit, too.

“We have a better understanding about the changes in different regions,” says Deashimikia Williams, who is the Fulton UBT’s labor co-lead. “Before the Super UBT, it was hard to get everybody engaged. Being engulfed in this work motivated us.”

LaDondra Hancock, senior account administration representative for Membership Administration in San Diego, also says the initiatives started by the Super UBT have improved the way she and her teammates work. “It has lessened the calls we get in from the different Member Services Contact Centers,” says Hancock, who serves as her local team’s labor co-lead and is a member of OPEIU Local 30.

Model practices

The success of this collective effort provides a model for other teams and departments looking to share and spread best practices, and underscores the importance of reaching out to other teams doing the same or similar work.

“Not only is this work of the Super UBT critically important for improving the member experience,” Monrad says, “but it also shows that it is critically important to test, model and explore new ways to bring improvement through our partnership that cuts across not only multiple regions, but multiple unions and multiple functions.”

Although Rahul Nayak, MD, calls himself “fundamentally lazy,” it might be more accurate to call him lazy like a fox. Instead of starting from scratch to create Georgia’s centralized Outpatient Safety Net Program, his team started with a recipe provided by Southern California.

“Someone has already done something that works. Why not start there?” says Dr. Nayak, who was physician program director of patient safety for Georgia when the program launched.

Dr. Nayak’s outlook serves as the guiding force behind spread—the art of adopting a practice, workflow or project from another team, medical center or even an entire region. The benefits? As the Georgia team learned, new initiatives often get off the ground faster if they’re modeled on an already proven concept. The Southern California safety net system had already won a 2012 David M. Lawrence Patient Safety Award for its work.

“The foundation was laid,” says safety net team member Eula Maddox, LPN, a member of UFCW Local 1996. Maddox makes up to 60 calls a day, phoning members who have had abnormal lab results and scheduling follow-up appointments. “These calls reduce stress for patients and costs for Kaiser Permanente,” she says. But, she notes, the team had to adapt the program for it to work well for Georgia members, including changing the hours that calls were made.

For its work, the team won the 2014 David M. Lawrence Patient Safety Award in the transfer category—an award for a region that successfully implements a project from an earlier award winner. The award recognizes the importance of spreading best practices, which ensures that members receive the same high level of care regardless of which medical center they visit. That’s a primary principle of One KP, which sets the goal of providing every health plan member with “the best experience, everywhere, every time.”

“Our members and customers believe—rightfully so—that we know how to operate as one organization,” says Bernard J. Tyson, KP’s chairman and CEO, “and that whatever we learn about the best ways to care for people in one geographic area…is available to all of our 9.6 million members.”

Best practices occur at all levels and in all departments. In Colorado, for example, the Regional Lab unit-based team tackled the issue of standardizing labels. Even a simple mistake—putting a label on crooked—can adversely affect patient care. The team is creating visual aids and tip sheets that will spread to 28 locations by this fall.

“This is a problem people have had to deal with for years and are passionate about fixing,” says Beth Fisher, a medical technologist, member of UFCW Local 7 and sponsor for the regional lab team.

Spreading practices takes effort from both sides. At Virginia’s Burke Medical Center, a project launched by the Primary Care team four years ago has sustained its success in helping patients with hypertension get their blood pressure under control—and the team has helped other facilities in Northern Virginia adopt the practice.

“If it works for us, it will work for other people,” says the Burke team’s lead nurse, Angela N. Williams-Edwards, RN, a UFCW Local 400 member. “Other teams saw it was easy and ran with it.”

After their letters to members went unanswered, the members of the Burke Primary Care team changed their approach.

Instead, clinical assistants called patients with the message, “Your doctor is concerned that your blood pressure is not being controlled,” says Angela N. Williams-Edwards, RN, a member of UFCW Local 400, the team’s lead nurse and former labor co-lead. “It worked better because it was more personal.”

This was in 2011, when the team had challenged itself to get more patients’ blood pressure under control and reduce their risk of a wide range of diseases. They succeeded—and their success mushroomed, with the other centers in Northern Virginia adopting it. All Primary Care teams share the goal of having more patients with blood pressure in a healthy range, and there was no reason for the other teams to start at square one since Burke had demonstrated its way worked—and worked well.

Four years ago, to entice members to come in more frequently to better manage their hypertension, the Burke team also made changes to make the visits for blood pressure checks as appealing as possible:

• Patients could pop in almost any time for the mini-checks, so they could stop when they were at the medical center for other reasons. There was no copay for the quickie visits.
• The members don’t have to wait long. “If they wait too long,” Williams-Edwards says, “their blood pressure will go up.”
• If a member’s blood pressure reading was too high, the doctor came in during that same visit to discuss options—possibly making medication changes—and to urge the member to return for a follow-up within 10 to 14 days.

All of these factors helped the Burke unit-based team increase the percentage of patients whose blood pressure is under control from 75 percent in January of 2011 to 85 percent by August of 2011. Today, the team has not only maintained that improvement but surpassed it. As of November 2014, the team boasts that 90 percent of its patients with hypertension have their blood pressure under control.

“Burke worked so hard to have the results sustained,” says Eileen Chiama, who has been the team’s management co-lead and clinical operations manager for about three years. “We achieved these gains through the huddling process and by keeping focused on it. It became part of our normal workflow.”

Moreover, Chiama says, “The workflow process was shared with other medical centers. The way you spread is to find a champion—someone on the team who is so passionate about the goal.” She says Edwards-Williams is that champion at Burke. “Never underestimate the power of one to generate enthusiasm in the rest of the team.”

Marianne Henson, RN, who was the team’s manager when the project first started, says she met regularly with the area’s other internal medicine clinical operations managers. “We share best practices that way,” she says. Now, several Northern Virginia teams—including Henson’s current teams at Falls Church and Tysons Corner—have improved their rate of blood pressure control, too.

When Marianne Henson, RN, left her position as clinical operations manager of the Burke Primary Care team in Virginia, she took something with her—a plan.

In 2011, Henson helped launch a project at the Burke Medical Center that boosted the percentage of patients with their blood pressure under control. Instead of creating a brand-new plan to solve the same problem at her new facility in Falls Church, Virginia, she became a copycat.

“Why reinvent the wheel?” Henson says. “We already knew what worked.”

When Henson was in her role at Burke, other clinical operations managers and physicians from the 10 Northern Virginia medical centers held regular area-wide meetings that allowed teams faced with similar issues to learn from one another. As a result, other facilities began adopting Burke’s practice of having clinical assistants call members with hypertension to ask them to come in for more frequent blood pressure checks. Burke had already discovered that members ignored requests sent via mass mail, so the other centers didn’t waste time or money repeating that experiment.

“We have members waiting only five to 10 minutes,” says Andrea Brown, a clinical assistant at Falls Church and member of OPEIU Local 2. “We let them know over the phone that this will be a quick visit and they will be on their way.”

Brown and the other clinical assistants try to call at least five members each day to see if they can pop in for a check while at the pharmacy or when they have an appointment with a specialist. And each day, depending on the weather, between three and five patients take advantage of the mini-blood pressure appointments. “This brief visit is cost effective, saves time and helps us make sure the member is on the right track,” Brown says.

Brown says members have given her positive feedback because of the convenience.

“It made sense because the whole region was expected to bring hypertension control up to better levels,” Henson says. “We standardized what we do.”

On her last day at work before going on maternity leave, something started going wrong with Juanita Ichinose’s pregnancy—and she found herself in an ambulance, on her way to the Downey Medical Center. Her husband, Trav, followed in his car. The images from an ultrasound foretold a grim story: Juanita was expecting twins, but one of the boys was not moving. “Code Pink” began blaring from the overhead speakers as she was wheeled to the operating room. What caregivers and the family feared came to pass. One twin survived, but the other did not.

“We had some moments with our other son,” says Trav Ichinose. “Then I went to see Teo. He weighed a pound and a half. The doctor told me, ‘He is very small.’”

Thus began Teo Ichinose’s four-month stay in the neonatal intensive care unit, a journey that led his father to become an active member of the department’s parent advisory council. Today, Teo is a happy 4-year-old, obsessed with his toy airplane from the latest Disney movie. And his father continues to bring the voice of the patient to Downey’s NICU unit-based team, where his input has helped shape numerous improvements.

UBTs exist to include all voices—employees, managers and physicians—in efforts to improve performance. And some UBTs are bringing in one more crucial voice: the patient’s.

To be sure, there are UBT members who resist. Objections range from “we don’t have time” to “patients can’t possibly know how our department runs.” But for others, it is a step that literally brings the patient-and-member focus of the Value Compass to life.

“UBTs have a lot of expertise. They know what is and isn’t working,” says Hannah King, director for service quality for unit-based teams. “What is missing is the perspective of the user, someone who might be afraid or in pain. We don’t know what they go through before and after they come to us. So we need to ask.”

Read on to see how UBTs have included patients and members in their work and improved performance.

Whose handoff is this, anyhow?
Downey NICU finds a way to keep parents involved during shift changes

During his son’s four-month stay in the NICU, Trav Ichinose became concerned that parents were prevented from visiting during shift changes, when the Nurse Knowledge Exchange Plus occurs.

“Parents want to maximize their time with their babies, and the policy was undermining that,” he says.

Nurses wanted to integrate parents into the process but also needed to prevent interruptions. “During the report, the parents tended to interject,” says Marnie Morales, RN, the team’s union co-lead and a UNAC/UHCP member. “That was a safety issue,” because it is important nurses not get sidetracked.

So, together with Ichinose and the parent advisory council, UBT members devised a system that met the needs of caregivers and parents. There would be “quiet time,” when parents listen and jot down notes while the outgoing nurse updates the incoming nurse. Once they’re done, it’s the parents’ turn to discuss their baby’s care with the nurses.

In testing the process, the nurses realized they needed to be able to discuss sensitive information out of the parents’ earshot—if, for example, there was a domestic violence situation or mental health problems in the family. So they came up with a discreet cue that signals the need to step away.

“The patient is getting better care because there is better communication. Information that wasn’t getting shared before is now,” Morales says. “As nurses, we get so involved with charting that we forget the patient is sitting there. Now, we are explaining as we are doing it because the parent is there watching.”

The change gave the team a boost in its satisfaction scores, which rose from 74 percent in the third quarter of 2012 to 88 percent one year later. It works to maintain the scores by holding refresher trainings with staff.

“With long stays like ours, your emotional resilience is tested to the max,” Ichinose says. “There are things that happen in the NICU setting that can undermine that resilience—or bolster it. Bolstering our ability to take in information, to be physically and emotionally present for the care of our child, affects our satisfaction with the care.”

Preserving pride, preventing falls:
A comment provides a San Diego team with fresh insight

Why do patients fall when they are in the hospital? Is it because they are elderly? Or under the influence of medications that affect their balance? The leaders, physicians and nurses at the San Diego Medical Center considered a range of possibilities and tried everything in the usual playbook, posting pictures of falling leaves on patient doors and using color-coded armbands to indicate fall risk. But nothing was working.

Then the UBT on the 5 West medical-surgical unit cared for a patient who was a member of the facility’s patient advisory council—and they asked his wife for her opinion. She said her husband—normally a self-sufficient, strong man—was too embarrassed to call a nurse to help him to the bathroom, especially given that he was wearing a flimsy, possibly revealing hospital gown.

That “aha” moment led the UBT to take a new approach: No one walks alone. Instead of trying to figure out who is at risk for falling, caregivers would treat everyone as a fall risk and provide assistance. The pilot program was so successful that it is being spread to the entire hospital. Before the campaign began in November 2012, the hospital had been averaging 16 falls a month. In June 2014, that figure was 3.4 a month.

Seeing the experience through the patient’s eyes was the key to the solution.

“I felt as if I was part of the team, and my input was just as valuable as any other member’s,” says Pat, the patient’s wife (last name withheld at her request). “If you go to patients with the attitude that they will be helping you do your job better, you will get an honest evaluation of what can be done to help, and they can make your job easier and more rewarding.”

Reluctant to change?
Some ideas for including patients as part of a UBT

Sheryl Almendrez, the management co-lead of the Definitive Observation Unit (also called a step-down unit) at the San Diego Medical Center, acknowledges that caregivers on her team were hesitant to have a patient join its improvement work: “They were interested, but were they ready to hear ‘the real truth’?” And what if a chronic complainer ate up valuable time?

As it turns out, there was little to fear. Patients’ requests were reasonable. For example, they want nurses to give them a heads-up when using an ear thermometer. “We’re used to it,” says Almendrez, but they may not know what it is. “They may think it’s an injection coming at them.”

For the Urgent Care unit in Largo, Md., listening to patients’ feedback about long wait times when coming in with a sore throat led that UBT to work with colleagues in the lab to fast-track tests for strep throat.

“Our team was very hesitant about bringing a member in because there could be more complaints than real feedback,” says Donna Fraser, RN, the team’s union co-lead and a member of UFCW Local 400. Making it clear why it was including patients helped: “We told the patient that we want to know what we are doing wrong, because how else will we improve?”

Morales of the Downey NICU says she no longer flinches from criticism, whether or not it’s phrased “constructively.”

 “Some of the people we have on our advisory council are the ones who complained the most,” she says. “You know what? They became the advocates for all the other babies. They helped us change a lot of things on our unit for the better.”

Close to 5,800 KP members in the Mid-Atlantic States get their Kaiser Permanente coverage through SEIU 32BJ, a regional union representing building service workers. Many of them speak English as their second language. To help this group get the most for their health care dollars, KP and 32BJ kicked off a campaign in April and May to educate and engage new 32BJ union members.

Maria Naranjo, deputy director, SEIU 32BJ Capital Area District, led the campaign with the help of Brenda Muñoz, labor liaison and analyst, KP Office of Labor Management Partnership. The field team included two 32BJ staff members and seven 32BJ members (four were bilingual). Of the seven 32BJ members, six already were KP members who could share their own experiences with KP.

“We want 32BJ members to be champions of health and KP in their workplace—and to do this, they need to understand their plan coverage and how KP works,” says Muñoz.

Team hits the field

The team visited close to 300 worksites and collected more than 1,100 names and phone numbers of members they spoke with. In addition, 32BJ sent 5,000 text messages and KP’s Regional Access Services staff placed more than 2,600 outreach calls to help members choose a physician, make appointments, identify health needs and learn about an upcoming heath fair. The goal was to provide as many touch points as possible by contacting members via mail, phone and in-person visits.

At the end of the campaign, Kaiser Permanente and 32BJ hosted a health fair at the D.C. Convention Center. It was the first time 32BJ partnered with a health plan to host a health fair. More than 100 32BJ members and family members attended and were offered free health screenings for blood pressure, BMI, glucose and total cholesterol.

Attendees also had a chance to meet with a KP physician, enroll in My Health Manager, select a primary care physician, make future appointments, ask questions and learn more about the KP system. Additional resources at the fair included workplace safety tips, healthy lunch tips and answers on health plan benefit questions. SEIU 32BJ was impressed with the health fair, which got positive feedback from attendees.

Creating value for members

Throughout the campaign, the team learned a lot about KP’s SEIU 32BJ members and their needs. The team identified several areas for improvement, and it is determining how to continue to engage these members through workshops, further education, health fairs and promotion of preventive health.

“SEIU 32BJ is a potential growth area,” Muñoz says. “In order to retain these members and encourage growth, we must provide the resources they need to show them that KP is not only committed to providing them with high-quality health care, but that we can provide culturally competent care.”

An earlier version of this story appeared in Inside KP Mid-Atlantic States, July 2, 2014.

When Donna Fraser sees something that needs doing, “I like to get it done,” she says. Twenty-one years ago, she joined Kaiser Permanente as a clinical assistant, one of the first in the Mid-Atlantic States region in the urgent care setting. After a few years, Fraser led a couple of her colleagues in approaching their supervisor at the Camp Springs, Md., facility about moving beyond registration and clerical duties to assisting nurses with patients’ health care needs.

“I said, ‘We believe you can utilize us.’ I knew I could do so much more to help out when the nurses were busy.”

She found a training program that ran from 8 a.m. to 2 p.m. five days a week. Meanwhile, she worked 3 p.m. to midnight shifts, mainly on weekends, and completed her courses in about three months. After struggling mostly on her own to pay for certifications in performing EKGs, phlebotomy and other tests and specimen collections, Fraser joined the facility’s fledgling class of urgent care technicians.

Hard work, good support

Today she is the lead RN at the Urgent Care/Clinical Decision units at the Largo Medical Center Hub, one of the newest facilities in the region. Fraser, a member of UFCW Local 400, says she owes much of her success to one of the Labor Management Partnership’s scholarship and wage replacement programs.

“I grew up here,” says Fraser. “It’s a great company if you work hard. You have to show up to win, do the best job.”

Trying to get an education while working full time is not easy, even for someone as motivated as Donna Fraser. That’s why LMP’s Ben Hudnall Memorial Trust was created, to support lifelong learning for union coalition-represented employees.

Wage replacement allowed her to take time off from her regular work schedule to attend classes, continue her employment, and keep up her clinical skills and knowledge. She’s taken advantage of the program twice since her first promotion, becoming an LPN in 2009, an RN in 2011. Fraser became a lead RN in 2013.

Click to enlarge.

Taking ownership

Jennifer Walker, the Mid-Atlantic States region improvement specialist who works with Fraser’s unit-based team, has seen greater benefit to the training. “Donna has become the person who organizes her group, serves as a support to all and keeps the team motivated,” Walker says. "And she has done this while working a full-time job and raising a family.”

But Fraser credits the Ben Hudnall Memorial Trust program with giving her a sense of ownership and responsibility for her education and her career. “We did the scheduling,” she says. “The big difference was the empowerment our manager gave us. As long as we could find the backfill, we went to our classes.”

The keys, says Fraser, are a supportive supervisor who “believes in the partnership” and a willingness to look to the union as a positive force: “Sometimes when you are an employee, you think you just use unions for when you are in trouble.”

The greatest challenge is helping people see that if they are involved in the process, it will be easier to move up.

“You can always find places within KP that need your expertise,” she says.