Northern California

Inspired by the goals of the worldwide “Baby-Friendly Hospital” initiative, the Health Education UBT at the Manteca Medical Center in Northern California set out in early 2012 to increase the percentage of new mothers who exclusively breastfeed. At the time, the number stood at 70 percent.

Steps emphasized by the initiative, sponsored by UNICEF and the World Health Organization (WHO), include training health care staff to inform every pregnant woman of the benefits of breastfeeding and to help mothers begin breastfeeding within one hour of giving birth.

Closing care gaps

The challenge was that while Manteca health educators provided prenatal services to expectant mothers, the moms went to Modesto to deliver their babies. The Manteca employees didn’t always learn whether their patients ended up breastfeeding. In order to make sure their patients were getting full support for breastfeeding as they made the transition from prenatal care to labor and delivery and beyond, the members of the Manteca UBT reached out to their hospital colleagues.

“As a Health Education department, we provide breastfeeding education during their prenatal care, but we were not reaching 100 percent of…moms after they switched to hospital services,” says Maria Prieto de Milian, a health educator, lactation consultant and active SEIU-UHW representative on the Manteca UBT. “There was not a consistent breastfeeding message.

“Our moms were in need of a continuum of care for breastfeeding.”

Researching best practices

The Manteca team, which meets monthly, is linked to a larger Health Education UBT at Modesto. The larger team meets quarterly and includes Modesto employees as well as the employees from the smaller teams at Manteca, Tracy and Stockton.

After researching best practices in breastfeeding support and exploring what other Kaiser Permanente locations were doing, the Manteca team introduced two small tests of change:

• Working with the larger Modesto UBT and with full support from the Women’s Health department, the Manteca team set in motion a collaborative approach to breastfeeding support involving health educators, lactation consultants, physicians, pediatricians, medical assistants and nurses. This includes hospital employees encouraging observance of the “golden hour” immediately after birth, when a newborn is placed skin to skin on the mother’s chest to promote bonding and breastfeeding.
• The team worked with other employees to make sure mothers-to-be were asked about breastfeeding at the regular 28-week prenatal visit, and that their questions or concerns were directed to lactation educators for follow-up.

The results were dramatic. By the end of 2012, 92 percent of Manteca prenatal care patients who delivered at the Modesto hospital were exclusively breastfeeding.

The umbrella UBT decided to spread Manteca’s idea.

“We turned it into a service-area initiative. It started as a pilot just for Manteca, and then the group decided it was so beneficial we’d roll it out to the whole Central Valley,” says Jose Salcedo, the management co-lead for the larger UBT. “The results were really conducive to parents and moms having a great experience. It’s a whole pathway from the early stages of pregnancy to the delivery and then to the pediatricians.”

“The breastfeeding initiative is now regular workflow throughout the Central Valley,” Salcedo said.

Good results sustained

At the time the Manteca UBT started its effort to improve breastfeeding rates, the Modesto hospital was working to achieve the Baby Friendly designation from the UNICEF-WHO program. After making significant progress toward that goal, it switched its focus to implementing the Northern California region’s Breastfeeding Toolkit, a new program that encompasses the same goals.

It's now been almost two years since the small tests of change, and Prieto de Milian says the Manteca UBT no longer is tracking the rate for its moms, viewing the project as a continued success.

New ideas are continually being added to strengthen the process. These include the advice call center providing 24/7 breastfeeding support while also scheduling follow-ups to the calls with lactation educators. In addition, lactation consultants are available to assist pediatricians by phone or by email on KP HealthConnect® during patient appointments.

With everyone’s minds and hearts on one goal, Salcedo and Prieto de Milian say, teamwork was seamless.

“What I like about the UBT is it’s a joint effort,” Salcedo says. “We have really good lactation educators who think outside the box, search for best practices and apply them. They went ahead and ran with it and made the recommendations. Management supported them all the way.”

For San Jose Medical Center’s inpatient pharmacy, the road to becoming a high-performing team first required a step—actually a jump—backward.

When the unit-based team was launched in 2010, it quickly was rated at Level 4 on the Path to Performance, the scale for evaluating a team’s effectiveness. The highest level is 5.

“We took it seriously and followed the process,” says Anita Nguyen, inpatient pharmacy director.

Then, in 2012, Nguyen, along with the team’s management and union co-leads, met with UBT consultants to assess their team performance. As they ticked down the list of questions and started to contradict one another, it became painfully clear: They were not the high-performing team they had previously thought.

“As a team we couldn’t answer the questions,” Nguyen says. “It was embarrassing.”

They were knocked down to a Level 1—the most fundamental rating.

Today, the team is a true Level 5, a highly functioning team that recently completed a successful stockroom project to reduce how many drugs are wasted, which is saving more than $10,000 a year. The success is a direct result of opening the department’s budget to the team, which only came about after team members started speaking frankly with one another.

The team’s downgrading was a painful, humbling blow, but most members agree that the assessment was valuable in putting the team on track to do this work and to earning the highest performance rating.

“I was not aware of what a UBT could really do for staff and managers,” Nguyen says. “We recognized the failure and I said, ‘I need you. Let’s work together.’”

Transforming teams

Inpatient pharmacy was one of several teams that shared their transformation stories at an event in July at San Jose Medical Center for national Labor Management Partnership leaders. The meeting spotlighted the medical center’s innovative approach to evaluating UBTs and supporting them in delivering the best care possible to Kaiser Permanente members.

Every quarter, San Jose UBT union and management co-leads sit down with their union and management sponsors, and with UBT consultant Heather Williams and Union Partnership Representative Eric Abbott, who support UBTs for the service area. Together they compare the team’s development against the traits outlined in the Path to Performance, including communication among team members and the status of improvement projects. The group then develops a plan for closing gaps, removing barriers and advancing to the next level.

The power of the process is in asking the critical questions, says Joan Mah, the UBT consultant for the San Rafael Medical Center, which has adopted the assessment practice. “Can your team members talk about the metrics? Kinda, sorta? Well if they can’t, we need to connect them with the skills to learn how. The whole point of this is supporting and strengthening. It’s an honest conversation.”

The assessment requires time and commitment from all parties, but by many accounts it is well worth the investment. In addition to San Rafael, which is seeing teams transformed through the process, the approach is being piloted in the Diablo and the Central Valley service areas.

The leap forward

For San Jose inpatient pharmacy, as candid and rigorous as the evaluation process was, it was also invaluable.

“We had to talk about what we really wanted,” says union co-lead Gubatan, an SEIU-UHW steward. “We basically said, ‘Let’s be truthful now. Let’s really do the work.’ ”

The team dramatically improved communication, developed trust, and engaged its members in the journey toward improvement.

“Everyone is empowered to contribute to this process,” Nguyen says. “Before, nobody questioned. Now everyone is empowered to question. With that, people feel like they really belong to the process.”

Summer interns often are put to work fetching coffee or making copies. But last year, UBT consultant Geoffrey Gamble wanted to create a more valuable experience for the teens of KP’s Summer Youth Employment Program at the Modesto Medical Center. So he trained a small army of performance improvement consultants to help support unit-based teams.

Despite initial skepticism from some team members and managers, the results were stunning. By the end of the summer, 12 of the 13 teams supported by the interns advanced at least one level on the Path to Performance. What’s more, four of the 19 projects carried out by the UBTs yielded savings or cost avoidance totaling $400,000. The program was such a success, it has returned to Modesto this summer and has spread to the Sacramento and San Jose medical centers. And in the process, the interns are gaining on-the-job training that translates to their studies and to the work world.

“I went in thinking we were going to do grunt work, but in reality it was like, ‘Wow, I’m actually doing something I can apply,’” says Nate Aguirre, who interned in Modesto’s Emergency Department last year. “It was a life-changing experience.”

The Community Benefit program has offered training and work experience to teenagers in underserved communities since 1968. In the past, that experience included clerical work or coaching on speaking in front of a large group. When Modesto’s internship coordinator retired in 2013, Gamble agreed to oversee the program as long as it supported his work developing UBTs.

Overcoming doubt with results

“When I first proposed the idea, directors were very skeptical,” Gamble recalls. “People would say, We’re struggling to do this with professionals—how do you expect to get momentum from a 16-year-old?’”

But Gamble saw the opportunity to offer teams a fresh perspective and the daily support many need to get started. He also wanted to show team members that performance improvement didn’t have to be complicated and could be incorporated in their daily work.

“I told managers that I was going to treat (interns) like adults and give them the skills I would give employees,” Gamble says. “If you hold them to that expectation, they will rise to the occasion.”

In the first few days of the eight-week program, Gamble trained the 16-year-old interns in basic performance improvement tools, including the Rapid Improvement Model, process mapping and Labor Management Partnership basics. By the second week, the youth were assigned to Level 1, 2 and 3 unit-based teams and started helping the teams launch projects and enter data into UBT Tracker.  

Rosemary Sanchez, Modesto’s Emergency Department supervisor, was one of the loudest doubters.

“At first I was like, ‘Ugh, one more thing to do.’ But then I thought, ‘OK, this could work and help us accomplish our goals and share our knowledge.’” 

Intern Nate Aguirre was crucial in helping the team on its project to streamline and standardize supplies in the treatment rooms.

“Nate was awesome,” Sanchez says. “He was so enthusiastic collecting data.”  

Getting the ball rolling

Aguirre also spent time talking to employees in the department to learn about their jobs and the challenges they face in their work.

Meghan Baker, an Emergency Department clerk and union co-lead for the UBT, says that sparked interest and support from UBT members—a shift from before, when they had struggled to get employees involved.

“People were into having their voice heard by someone,” says Baker, who's a member of SEIU-UHW. “Now people are talking and getting the ball rolling on things. And we’re making it known that people are being heard.”

At the start of the program, the Emergency Department UBT was ranked at Level 3. The team advanced to Level 4 after completing the work.

Michelle Smith, manager of Specialty Surgery Reception, appreciated the new perspective and support her team received from its intern for its project to reduce surgery no-shows and last-minute cancellations.

“It was nice to have someone get our project going,” she says, “because we were at a standstill.”

The team’s intern walked the UBT members through mapping out their process. New workflows emerged that included calling patients ahead of scheduled surgeries, which reduced no-shows and increased service scores.

When the teams were asked what they thought helped them advance, many said it was because of the interns coming to the departments every day to help push and support the work. 

“We would have eventually worked on the project, but having her come in and start us off in a positive way was great,” Smith says. “She taught us how to be a team, because we realized we all had to be part of the work.”

For more than 10 years, Kaiser Permanente’s Child Health Program has been veiled in relative obscurity despite the extraordinary service it offers.

Even more unknown is the role KP enrollment processors in Northern California, who are represented by OPEIU Local 29, are playing in helping the charitable health program fulfill KP’s mission of serving our communities.

“I like to say that we’re the best-kept secret of KP,” says Sharlene Jones, an enrollment processor who screens applicants for eligibility and guides them through the sign-up process. The community benefit program provides comprehensive medical, dental and optical coverage at little or no cost to children ages 19 and younger whose family income falls below the federal poverty level and who have no other coverage options.

Since August, the Oakland-based enrollment processors have attended more than 40 health coverage enrollment or outreach events across Northern California, from informational sessions at small medical clinics to large events like the “We Connect Health Care” enrollment and resource fair in Fresno, which drew thousands of people. The processors answer any question thrown at them about the Child Health Program and help enroll those who qualify.

“Our processors are able to help families right on the spot,” says Sara Hurd, a former employee who until recently led outreach for the program. “They know what challenges are and how to work through them.”

Long-lasting value

The Child Health Program has a goal of enrolling 80,000 qualified children across Northern and Southern California. The work the Local 29 members are doing to help meet that goal fits within the framework of Labor Management Partnership efforts to grow the number of Kaiser Permanente members—and to establish positive member relationships that can last a lifetime.

As outreach coordinator, Hurd’s priority was getting the word out about the program and forging relationships with community organizations. She also served as the sole contact for prospective applicants at outreach events—but she didn’t have the detailed enrollment knowledge the Local 29 processors have.

Maury Rosas, manager of Charitable Health Coverage operations, reached out to enlist the processors’ help. Including them in the work, Hurd says, “has been invaluable”—and as of May 2014, more than 77,000 children were enrolled.

“We needed people who really understood what the applications are about and could help people with eligibility,” Rosas says. Before he requested their help in the field, the enrollment processors’ interactions with potential qualifying applicants were by phone or letter.

“We’re able to answer their questions,” Jones says. “It allows us to put a face on KP.”

Many of the processers who attend the events have bilingual certification and are skilled in walking applicants through enrollment in Spanish.

“It’s important to show (the public) that we’re not just sitting behind a desk, pushing papers,” says Miriam Garcia, an enrollment processor. “We’re the labor force behind it all….We’re here to work with the community and are proud of KP.”

Demonstrating a commitment

The effort has been an unqualified success, Rosas says, from community agencies asking for repeat visits to the response of the children’s parents.

“They took me by the hand and walked me through the process of completing the application and made me feel comfortable with the process,” says Rufina Garcia, speaking through a Spanish interpreter. Garcia enrolled her three children in the program at an outreach event in March. “This has been the first time when I could walk in and give my information and be signed up right there.”

Delivering on KP’s mission in partnership between labor and management also helps build relationships with potential union-oriented purchasers of health care, says Katy McKenzie, a consultant to LMP and its membership growth work.

“It goes a long way when you’re talking to unions that represent low-wage workers,” McKenzie says. “They see that we actually do care about caring for people and our communities. It’s not just about selling something to them.”

McKenzie and others involved in the growth work helped promote the Child Health Program to unions representing low-wage or part-time workers, such as laundry or home care workers—people who don’t get dependent health care coverage as part of their job benefits or who can’t afford what is offered to them.

 “It’s a great opportunity to see that management is working with labor as a team,” Miriam Garcia says. “We’re not only supporting KP, but we’re supporting our own labor force.  We’re showing that we can work together and make a change. We’re helping make a change that carries over into the community.”

That kind of caring makes an impression. Rufina Garcia, who only has catastrophic medical coverage for herself, says she would choose Kaiser Permanente for her whole family given the chance.

“It has been a wonderful experience,” she says. “The way they treat my children is incredible. (The doctors and nurses) are very caring—they have more patience and actually listen to the kids….I believe they take better care of my children.”

If people understand why we’re asking them to do certain things, they are more likely to help find solutions. That’s why unit-based teams, and their sponsors, must understand the implications of the Affordable Care Act to lead meaningful change.

The ACA is producing unprecedented changes in the marketplace. It is opening up health care to people who had little or no access to routine care before, and giving them choices they never had before. But for many, the choice will come down to dollars and cents—which means Kaiser Permanente needs to do two things, in partnership:

First, to attract new members, we have to offer competitive rates. Then, we have to wow them when they call or visit—especially the first time they call or visit

Know your role

As UBT sponsors, we have to ask ourselves: How are we going to do an awesome job of caring for patients and being the most affordable if our team doesn’t understand the impact it can have and isn’t involved in helping find solutions?

We need to understand what our role is in helping teams improve service and efficiency. If we, as sponsors, recognize that unit-based teams give Kaiser Permanente a competitive advantage and a way to drive change, and we provide the support for that work, we’ll largely have succeeded in our role.

Work with your team

When a manager or sponsor comes to me with an issue or area for improvement, one of the first things I ask is: Are you working with your UBT on this? If not, I ask them to try again—because becoming more efficient, cost-effective and member-centered doesn’t happen just in the administrative suite. It happens with the frontline staff and physicians. If sponsors, leaders and managers look to UBTs and their expertise, it will lead to solutions.

Sponsors and leaders also need to ask themselves: Have we figured out what resources the UBTs need to get the work done? Do they need the time, the meeting space, and a facilitator?

UBTs are only as good as the leaders who invest in them. We have more compelling reasons now than ever to leverage the partnership. If team members understand those reasons and are given direction and support by their sponsors, there is no limit to what we can do to help Kaiser Permanente continue to lead in this time of change.

South San Francisco allergy team’s specialty may be allergens and hay fever, but that didn’t prevent it from helping to improve patients’ screening rates for cancer, too.

It didn’t happen all at once—some staff members were skeptical at first. Scheduling a screening appointment for a wheezing patient didn’t seem right.

“At first people would say things like, ‘You know, I really don’t feel comfortable saying to a patient, “Oh, you’re due for mammography” when they’re sneezing and congested and here for allergies,’” says Alva Marie Aguilera, the department’s supervisor and management co-lead for the unit-based team.

Screenings as strategy

But part of delivering on Kaiser Permanente’s Total Health promise is to identify health risks and signs of disease as early as possible. Regular screenings for such diseases as high blood pressure, diabetes, and colorectal, cervical and breast cancers are an important part of our strategy.

That means caregivers and employees in seemingly unrelated departments—not just those in, say, internal medicine—have a role to play, and KP HealthConnect® provides them with a powerful tool.

Any time a patient is seen, a “proactive office encounter” message pops up in the member’s electronic record if he or she is due for a health screening or if important health data needs to be updated. It doesn’t matter what the reason is for the current visit or which department the patient is being seen in. 

The members of South San Francisco allergy department took the important work of taking the next step to heart: Following up on the prompt and offering to schedule the patient for the screening or asking the necessary questions to fill in missing information.

Scripts and reminders

To help make sure those things happened consistently, the team tried some small tests of change:

• It created a general script to help broach the questions with patients and posted laminated cards on computers to serve as reminders.
• Aguilera reports the weekly screening numbers so staff members know how they are doing and where they missed opportunities to follow through on the HealthConnect® prompts.

The small changes had a big impact. Before the team started the project in February 2012, it followed through on the prompts 80 percent of the time. In the first two months of the project, that jumped to 90 percent. By early 2013, the prompts were being followed up on 95 percent of the time and held steady at that rate for the rest of the year.

It wasn’t just staff members who were uncertain of the practice in the early days.

“At first it was kind of surprising to patients,” says medical assistant Lidia Vanegas-Casino, a member of SEIU UHW and the UBT’s union co-lead. “So we had to explain to them: ‘It’s a way to help you, and to keep up with the things you need done. It’s a proactive approach to keeping you healthy.’”

Positive example

It was one of KP’s own commercials that convinced team members of their important role in keeping patients healthy. Aguilera showed the ad that features KP member Mary Gonzalez, who had gone in—fittingly—for an allergy appointment when the receptionist noticed she was due for a mammogram and booked an appointment for her. The screening picked up a mass, and Gonzalez subsequently learned she had breast cancer. The early detection helped ensure a positive result.

It wasn’t a primary care or OB-GYN department that got her that screening. It was allergy.

“It really hit home for people,” Aguilera says. “If it wasn’t for the allergy receptionist who took that time, we don’t know what would have happened. That was a big encouragement.”

Some departments glide effortlessly into becoming high-performing teams. Not so for the San Rafael Health Information Management team.

Now at a Level 5 on the Path to Performance, the team had to overcome numerous hurdles to get to where it is today.

“They went through a lot of hell to get there,” says Richard Orlanes, a regional LMP consultant who worked with the team during some of its darkest days. “To see the transformation they made in about a year—it was almost like they fired the old people in the department and brought new people in.”

As recently as 2011, the team members, whose work is to maintain KP’s medical records, were negative and distrustful, their morale was low, and they didn’t participate during UBT meetings.

“You could hear a pin drop at the meetings—nobody said anything,” says Richard Incaviglia, an outpatient ambulatory coder, SEIU UHW member and the team’s labor co-lead. “At one time people even said they wanted to dissolve the UBT.”

Sponsor involvement is key

But instead, the co-leads—with assistance from Joan Mah, the local UBT consultant—reached out to the LMP regional office for help. They brought in Orlanes to observe the department and lead a series of interest-based problem-solving exercises. He also suggested including sponsors in the exercises; when the management sponsor accepted and also brought her boss to the meetings, it sent a message to the team that leadership really wanted to turn things around. To provide a sponsor perspective on the union side, the co-leads involved Kisha Fant, a union partnership representative, and Zachary Adams, a contract specialist.

“Bringing in the sponsor means everything. Her being there told us that this was a serious effort,” Incavigilia says.

The management sponsor, Freida Smith, the Marin/Sonoma HIM director, is now the team’s management co-lead. As she remembers it, she wasn’t so much invited to participate in the problem-solving sessions—she invited herself.

“I stuck my nose in,” Smith says. “I had to step in and assume some responsibility because the sponsor needs to be involved and is ultimately responsible.”

Discussing positions and interests

Smith believes that the turning point for the team came when they discussed their positions and interests with Orlanes as the facilitator.

“We had to decide as a team that there was nothing we could do about what happened in the past,” Smith says, “but we could step out on faith and move forward.”

After working with the LMP regional consultant for several months, the team members were finally ready to start working together on their common interests. They prioritized the issues of communication, trust and honesty, and transparency, and worked to transform the negativity in the department. One of their early tests of change was to introduce a daily 8 a.m. huddle. The team huddles over the phone because half the team members work remotely. After the huddle, Smith sends an email to the whole department summarizing what was discussed.

“Once we started communicating and voicing opinions, and we realized we didn’t need to worry about retaliation, everybody started participating,” Incaviglia says.

On to high performance

Now the team has a long list of successful performance improvement projects under its belt, including a project to reduce the number of medical records that have missing documentation and another to make sure charts are coded within four days or less.

Smith believes that being transparent was the key to success.

“No matter how small or large the issue, be transparent,” she says. “I share every single thing that impacts the team’s day-to-day existence, including the budget.”

These days Smith is not only the management co-lead of the San Rafael HIM team but also the sponsor of a team in Santa Rosa. Her advice for other sponsors of dysfunctional teams? “I think the key is to communicate with the UBT co-leads first and then, if things don’t improve, take it to the whole team.”