Northern California

Imagine developing a severe cough and teeth-chattering chills. You want to be seen by a doctor but no one really understands you: Not the call center operator with whom you try to make an appointment; not the receptionist who checks you in; not the medical assistant who takes your temperature and blood pressure. Not even the doctor who speaks quickly and uses complicated medical terms.

“When you come in for medical care, it’s already like a foreign land,” says Kathleen Kearney, the manager and the UBT co-lead for the Obstetrics and Gynecology department at San Jose Medical Center.  “If you don’t speak English, it can be downright frightening.”

Giving patients better access

Kaiser Permanente has long been committed to providing language access in the form of interpretive services for its non-English speaking members. The Ob/Gyn unit-based team in San Jose has taken the additional step of creating a Spanish-speaking module, a sort of one-stop shop for Spanish-speaking patients.

The idea for the module came from Joseph Derrough, MD, who recognized that good patient care involves more than just the patient and the physician in the exam room. It includes each interaction, from making an appointment to checking in and being assigned a room.

“I realized that we had a significant percentage of patients who only spoke Spanish, and we could do better service to them by providing linguistic and culturally competent care,” Dr. Derrough says. “We had staff that spoke Spanish, but they weren’t all in the same place. My vision was that we could create a clinic module where, from registration to examination, the patient was spoken to in her own language.”

Making it happen

The unit-based team made it happen.

“From the time they walk in the door, every patient should receive the same level of care regardless of the language they speak,” says Glenda Morrison, a medical assistant, SEIU UHW chief shop steward and the UBT co-lead.

But in the beginning, the frontline staff members, including Morrison, were skeptical.

“Since we were already serving Spanish-speaking patients in our clinic, the question we were asking was, ‘Why is this needed?’ ” Morrison says.

But a visit to the Spanish-speaking Medicine module at the Santa Clara campus made them believers. That module has been in place for five years.

“When I saw it in action, a light went off—and I realized that by not speaking to our Spanish-speaking members in their own language, we weren’t providing them with the same care as we were our English-speaking members,” Morrison says.

Overcoming obstacles

Once the team decided to take on the project, it faced some challenges. Offices had to be moved and medical assistants had to be reassigned.

“We had a lot of meetings and a lot of nervous people,” Morrison says.

But again, the Santa Clara example eased fears: “Once they saw how it worked in Santa Clara, we got by-in from the staff and it was easier,” Kearney says.

The module, which opened Sept. 29, includes signage and literature in Spanish. The staff members, from the receptionists and medical assistants to the doctors, are fluent Spanish speakers.  Word about the new module went out through Spanish-speaking television news and newspaper reports. And there was a grand opening.

It’s going well so far, Kearny says, noting that “we have three Spanish-speaking providers each day, and they have appointment capacity for about 20 patients.”

Next steps

Now, the team is looking for ways to quantify the benefits of the new module. It’s hoping to be able to collect patient satisfaction data specifically from Spanish-speaking members to assess the impact, Kearney says.

“If it shows success, we’ll pass the idea on to other teams,” she says.

Meanwhile, the unit is looking at how it can provide culturally competent care for its other monolingual patients.

“We don’t what a certain group to feel singled out,” Morrison says. “We just want them to feel comfortable.”

The employees in Charitable Health Coverage Operations (CHCO) felt good about their Northern California department’s mission—but not so good about how long it took sometimes to help the thousands of low-income children who benefit from KP-subsidized health care.

The department handles the eligibility paperwork for a KP program that provides health coverage to people who don’t qualify for employer-based health coverage or public programs like Medicaid. At the team’s low point in 2005, it had a six-month applications backlog.

“Our primary customers are children,” said Nancy Waring, CHCO customer care manager. “We have over 80,000 children, most of them low income. About 50 percent of our population is Spanish speaking. And the program is completely subsidized by Kaiser.”

Too large a group

In the past, one representative unit-based team encompassed the whole department.  Because employees within the same department were doing very different types of work—processing mail, entering data, processing enrollments, providing customer service, and servicing the regions outside of California—they didn’t share a single set of problems. So the UBT tended to work on departmentwide problems like attendance.

But the single UBT struggled.

 “We basically failed from 2006 to 2009 to do anything,” says Suber Corley, the department’s director, “simply because we were looking at too large a group trying to solve too large a problem.”

So they reorganized. The department now has five UBTs that correspond with employees’ functions.

Setting priorities

The smaller teams set their sites on a number of changes, but they also coordinated with each other on one common goal: to process every application by the 20th of the month.

In their UBT, the mail-room employees decided to look at priorities differently.

“We identified that what we really needed to do was to have a prioritization scheme for every week of the month,” says Victor Romero, CHCO operations manager. He explains that during the first week of January, a recertification application that’s due on April 1 would be low priority in the mail room, whereas a new application—which would need to be processed by January 20 for insurance coverage to begin on February 1—would be high priority. After the 20th, attention moves to the low-priority documents.

The data entry, scanning and enrollment UBTs came up with other solutions, too.

“We instituted several changes in how the application is handled,” says Carl Artis, an enrollment processor team lead and OPEIU Local 29 shop steward. “If we couldn’t process an application, the application was sent back to the customers very early so they could make necessary corrections. We also streamlined our process—there were some things we were doing twice, which wasn’t necessary.”

Artis emphasizes that the changes were developed jointly by frontline workers and managers.

“I have to admit they (the managers) have some really great ideas,” he says, “and they were really able to listen to some great ideas.”

It worked. In October, for the first time in the department’s history, the team was able to process all its new applications by the 20th, so coverage for those applicants could start in November.

“The end result is that poor children did not go without health coverage,” Romero says.

Addressing burnout

In addition to the project to reduce the amount of time it takes to process new applications, the smaller teams have taken on other projects, like reducing burnout among customer service agents who spend all day answering phone calls. They’ve also done charity work together, raising funds to provide school supplies for low-income students at a local high school.

Artis passes on the story of his department’s flourishing UBTs to other members of Local 29.

“I’ve heard some people say, ‘Oh, that’s too much work to take on,’ or, ‘We don’t have the resources we need to address the issue’ or ‘Management would never go for that,’ ” Artis says. “But what I’ve learned is—just try it, and don’t be afraid to fail.”

What happens when teams truly walk a mile in their patients’ shoes? They often discover their own actions are making that mile a rocky one for patients—and as a result make huge breakthroughs in the way they deliver care.

In the case of South San Francisco’s multidepartmental pre-admission team, observing their processes from the other side of the gurney spurred them to dramatically streamline the pre-surgery and admitting process for patients. With the member at the forefront of their thinking, the team members turned a two-inch-thick packet of confusing, redundant information into a streamlined, one-page checklist. And a funny thing happened—while redesigning the process to help patients, the team improved the way it works.

“Patients would often get confused and weren’t sure what the next step in the process was,” says Brian Tzeng, MD, the Peri-operative Medicine director. “We realized we didn’t have a clear path for the patient to follow.”

Other teams throughout Kaiser Permanente are making similar realizations, framing their performance improvement work by asking the question, “What’s best for the patient?” If a possible solution doesn’t work well for the member and patient, then there’s more brainstorming to be done. These teams are taking the Value Compass to heart—organizing their work not just around the four points but examining what they’re doing from the patient’s perspective.

What does that mean for frontline teams? At the San Diego Medical Center, the Emergency Department sees up to 300 patients every 24 hours. Physicians and staff members are always on the go, delivering on the ultimate bottom line—saved lives. What could be more important? Clinical quality is high; patients are seen in a timely manner and the rate of unscheduled return visits is good.

Yet the results of a recent patient satisfaction survey bothered the team. The department scored well overall, but their patients gave it only 63 percent approval on one question: While you were in the Emergency Department, were you kept informed about how long the treatment would take?